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

We decided that the Plan has to pre-approve facet joint injections for the enrollee.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that facet joint injections are 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 chronic low back pain. He is participating in a home exercise program. He is taking Zanaflex, Etodolac and Hydrocodone for pain. He has had prior facet joint injections which have provided him with greater than 50% pain relief. The records state that he received greater than 50% pain relief for more than 3 months. Therefore, the requested procedure 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 the requested services have been met. Therefore, we decided that the Plan has to pre-approve facet joint injections for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve SNF admission. The Plan denied your request. The Plan says SNF admission is not medically necessary.
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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment only in a SNF. The enrollee does not have a tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need. Her current blood pressure issues should be stabilized in acute care prior to participating in any rehabilitation/therapy program or returning to her home. She is noted to be at baseline function. This enrollee does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not require these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis". 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IV Emend for anti-nausea with planned chemotherapy treatment.
You asked the Plan to pre-approve the IV Emend. You say that the requested drug should be allowed for treatment of chemotherapy-induced nausea. The Plan denied your request. The Plan says the enrollee does not need this anti-emetic for this regimen and there is no evidence that the use of Zofran and Kytril would be ineffective or contraindicated.
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 IV Emend. Our reviewer says that the requested use of Emend is not considered reasonable and necessary based on standards of practice and step therapy requirements. Our physician reviewer found in the planned chemotherapy regimen, docetaxel (Taxotere) has a low nausea-causing potential and so does ramucirumab. Emend is indicated for high to moderate nausea-causing chemotherapy. Neither of these drugs fit this criterion. In addition, there is no documentation that he has nausea or vomiting. Ondansetron or Kytril are reasonable to try as first line in keeping with step therapy requirements. 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 IV Emend have not been met. Therefore, we decided that the Plan does not have to pre-approve IV Emend for anti-nausea with planned chemotherapy treatment.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of interlaminar/interspinous process stabilization/distraction device (22869 and 22870).
You asked the Plan to pre-approve the insertion of interlaminar/interspinous process stabilization/distraction device. You say that this is medically necessary. The Plan denied your request. The Plan says this procedure is 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 insertion of interlaminar/interspinous process stabilization/distraction device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found it is documented that an interlaminar/interspinous process stabilization/distraction device may help this enrollee's pain, but that with his level of pain, stenosis surgery is the best option. The enrollee refuses further surgical consultation. The evidence in the available peer-reviewed medical literature does not clearly support that interspinous distraction devices are safe and effective in the treatment of degenerative lumber spinal stenosis, in terms of effectiveness, side effects, recovery time, and long-term outcomes. 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 insertion of interlaminar/interspinous process stabilization/distraction device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of interlaminar/interspinous process stabilization/distraction device (22869 and 22870).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a Low Dose Computed Tomography (LDCT) Lung Cancer
Screening (G0297) provided November 13, 2019.
You asked the Plan to pay for the LDCT Lung Cancer Screening. You say that the service was medically
necessary. The Plan denied your request. The Plan says LDCT Lung Cancer Screenings are covered annually.
The enrollee has already had an exam in the past 12 months.
The Plan must follow Medicare rules. Medicare rules say that LDCT Lung Cancer Screenings are covered
annually.
We looked at the file and Medicare rules. The enrollee previously had a LDCT Lung Cancer Screening on
February 2, 2019. The screening rendered on November 13, 2019 exceeds the allowable amount per year.
Based on this information, we decided that Medicare rules for coverage of the LDCT Lung Cancer Screening
have not been met. Therefore, we decided that the Plan does not have to pay for a Low Dose Computed
Tomography (LDCT) Lung Cancer Screening (G0297) provided November 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an X-ray of the pelvis (72170) provided June 20, 2019.
You asked the Plan to pay for the X-ray. You say that the services were medically necessary. The Plan denied
your request. The Plan says the service at issue shares a Column I / Column II relationship with another code
already paid.
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, we have confirmed that code 72170
has a bundled relationship with code 73502 and cannot be paid as billed. This code cannot be paid as a separate
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided
that the Plan does not have to pay for an X-ray of the pelvis (72170) provided June 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on April 15, 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 to the enrollee on April
15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered to the enrolle on July 19, 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 PC is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that modifier -26 is required for separate payment of the PC of diagnostic services when furnished in a different payment locality than the TC. We looked at the file and Medicare rules. The file does not show that the PC of the services was furnished in a different payment locality than the TC. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on July 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on March 25, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained.
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 the denied codes is: CPT 80307: Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed. HCPCS G0482: Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed
We find that the denied codes are not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 drug testing services provided to the enrollee on March 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on November 5, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved
for payment. The Plan denied your request. The Plan says no prior authorization was obtained for these
services. The Plan says that the member's primary care physician is also out-of-network.
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 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 for an office visit provided on November 5, 2019 by
an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on July 25, 2019.
You asked the Plan to pay for the office visit. You say that you would like the Plan to reconsider their denial of
payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent
and prior authorization was not obtained to provide out-of-network/out of area care.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and
pre-approved care.
We looked at the file and Medicare rules. The file shows the office visit was not provided due to an unforeseen
illness or condition. The office visit was not provided due to an emergency or renal dialysis. The office visit
was not pre-approved. Based on this information, we decided that Medicare rules for coverage of the office
visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit provided
on July 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat
exchanger (99190) provided on September 25, 2019.
You asked the Plan to pay for the assembly and operation of pump with oxygenator or heat exchanger. You say
that this was a medically necessary service. The Plan denied your request. The Plan says payment of this
service is included in the DRG payment.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that
CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the
OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule.
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as
"inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the
Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger (99190)
provided on September 25, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Pembrolizumab.
You asked the Plan to pre-approve Pembrolizumab. The Plan denied your request. The Plan says that the medication is not supported with a PD-L1 less than 20%
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 Pembrolizumab. Our physician reviewer found that the requested use of Pembrolizumab is FDA-approved for your diagnosis as a second line. You were unable to receive a platinum due to hearing loss, but has received first line therapy with Cetuximab. The requested use is supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The documentation does support that the requested drug is safe and effective and otherwise 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 Pembrolizumab have been met. Therefore, we decided that the Plan has to pre-approve Pembrolizumab.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says skilled care in an inpatient setting is not medically necessary.
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 services. Our physician reviewer found that from a nursing perspective, you have stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, you are at a supervision level with functional mobility. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy services on a daily 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
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 the enrollee needs LTACH care. The Plan denied your request. The Plan says an LTACH is not able to provide any services that is superior to those available at the current facility.
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 in this case, the member still requires acute level of hospital care and is receiving appropriate care at the present acute care hospital. There is no documentation provided necessitating admission to a LTACH. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he 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. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the X-rays of the chest and shoulder (71046, 73030) provided on August 21, 2019.
You asked the Plan to pay for the X-rays. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not preauthorized or emergent. The enrollee has no out-of-network benefits.
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 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 for the X-rays of the chest and shoulder (71046, 73030) provided on August 21, 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 you feel that you need to be cared for in the IRF setting due to your increased risk of falling. The Plan denied your request. The Plan says you do not have any acute medical conditions and do not require an intensive therapy program with three hours of daily therapy.
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 member's medical condition is stable. The medical complexity of care is low. The review indicates that the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.