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

We decided that the Plan does not have to pay for radiology services (74018, Q0092, R0070) provided November 4, 2019.You asked the Plan to pay for the radiology services. You say that the services were medically necessary.The Plan denied your request. The Plan says Original Medicare is liable for payment for these services.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay for radiology services (74018, Q0092, R0070) provided November 4, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care could be received in another setting, such as skilled nursing facility, outpatient setting, or home health care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR). 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a total hip arthroplasty (THA).You asked the Plan to pre-approve the THA. You say that this surgery is medically necessary to reduce the enrollee's pain and increase function.The Plan denied your request. The Plan says that there is not sufficient documentation of the three month trial of conservative care.The Plan follows Medicare rules. Medicare rules say that THA is covered for enrollees with advanced hip joint arthritis when the above reference criteria are met. 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 THA. Our reviewer says that the requested THA procedure is considered reasonable and necessary based on the LCD criteria. Our physician reviewer found this enrollee presents with a now 5-month history of constant and worsening right hip pain, severe with movement and weight bearing. Clinical exam findings are consistent with radiographic evidence of severe joint space narrowing, subchondral sclerosis, and periarticular osteophyte formation. She has completed at least 3 months of conservative treatment for her right hip complaints, including altered activities, medications, ice, and corticosteroid injection. Under consideration is a request for right total hip replacement. Medicare coverage criteria have been fully met. There is radiographic evidence of advanced joint disease, pain and functional limitations in weight bearing activities, and unsuccessful non-surgical medical management for a minimum of 3 months. This enrollee has met all Medicare coverage criteria for the requested right total hip replacement.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 THA have been met.Therefore, we decided that the Plan has to pre-approvea total hip arthroplasty (THA).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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Liver Fibrosis Fibro Test - ActiTest panel provided to the enrollee on March 12, 2020.
You asked the Plan to pay for the testing. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation to indicate that this test has medical usefulness in primary sclerosing cholangitis.
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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the fibrosis panel test was medically necessary to diagnose, treat or otherwise manage the enrollee's condition. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the Liver Fibrosis Fibro Test - ActiTest panel provided to the enrollee on March 12, 2020.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While physical and occupational therapy are a reasonable part of the management of your condition, the records do not support a need for intensive rehabilitation services. 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 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.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve10additional physical therapy (PT) visits.You asked the Plan to pre-approve10 additional PT visits. You say that the 10 additional PT visits are medically necessary.The Plan denied your request. The Plan says the 10 additional PT visits are not medically necessary.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 10 additional PT visits. 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 reviewerfound the enrollee has received skilled physical therapy services since 5/28/20 for trouble walking, weakness and osteoarthritis.  The requested services are generally accepted as specific and effective therapy for these conditions but the submitted documentation does not support that the unique skills of a trained therapist are required to safely and effectively provide treatment or that the specialized skills, knowledge and judgement of a qualified therapist are necessary to establish, design or deliver a program to maintain the enrollee's current condition or to slow or prevent deterioration. The 10 additional PT visits are not necessary at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 10 additional PT visits have not been met.Therefore, we decided that the Plan does not have to pre-approve10 additional physical therapy (PT) visits.
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 for the enrollee.
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 the enrollee can safely receive the services needed 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. The patient is medically stable with no evidence of need for supervision by physical medicine and rehab Physician or need for acute rehab nursing care. Given her functional level she does not require IRF level of therapies. The patient may benefit from further physical therapy and an occupational therapy but does not require an intensive therapy program. IRF admission is not medically necessary based on the patient's current functional status and medical stability. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic office visits (99211) provided from February 5,
2020 to March 20, 2020.
You asked the Plan to pay for chiropractic office visits. You say that you needed these services. The Plan
denied your request. The Plan says these services are not covered.
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 records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for chiropractic office visits (99211) provided from February 5, 2020 to March
20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). You asked the Plan to pre-approve IRF care. You say that this is medically necessary.The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility, home with home health and home physical therapy, or home with outpatient 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 yo do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care (ex. SNF/SAR).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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (CPT Code 99232) and hospital
discharge day management (CPT Code 99238) provided to the enrollee from July 30, 2019 through July 31,
2019.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your
request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the services have not been met. Review of the file shows that that
the billed service, 99232 (Subsequent hospital care, per day, for the evaluation and management of a patient,
which requires at least 2 of these 3 key components) and 99238 (Hospital discharge day management; 30
minutes or less), billed by the provider, denied because 99225 (Subsequent observation care, per day, for the
evaluation and management of a patient, which requires at least 2 of these 3 key components) and 99217
(Observation care discharge day management) was billed by same provider, under another claim for the same
date of service. Therefore, we decided that the Plan does not have to pay for subsequent hospital care (CPT
Code 99232) and hospital discharge day management (CPT Code 99238) provided to the enrollee from July 30,
2019 through July 31, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Keytruda.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 that the services are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are medically necessary. Our physician reviewer found Keytruda is FDA approved for first line metastatic non-small cell lung cancer in patients with no driver mutations and PD-L1 staining of greater than or equal to one percent. The enrollee meets this criteria and has been stable on Keytruda since August 8, 2019 on a computed tomography (CT) scan from June 11, 2020. The Keytruda is reasonable and 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 these services have been met.Therefore, we decided that the Plan has to pre-approve Keytruda.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT).
You asked the Plan to pre-approve 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 National Comprehensive Cancer Network (NCCN) guidelines state that IMRT should only be used in the setting of a clinical trial or unique situations, such as re-irradiation or unique anatomical situations. The enrollee is not in a clinical trial and the records do not support a unique situation for which IMRT would be warranted. The requested IMRT is not reasonable or medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee can safely receive the services needed 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. The patient was medically stable with no evidence of need for acute rehab nursing care. Functionally given his participation, he does not require IRF level of therapies. The patient may benefit from further physical therapy and an occupational therapy but does notrequire an intensive therapy program. Our physician reviewer found that the enrollee's 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-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. You say that Keytruda is both medically necessary and an appropriate drug for the enrollee at this time. The Plan denied your request. The Plan says that the specific cancer requires the enrollee to not have previously experience disease progression while on or following therapy with Keytruda.
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 physician reviewer found that the enrollee has stage IIIB non-small cell lung cancer. The requested use of Keytruda is FDA-approved for the enrollee's diagnosis. This enrollee last received immunotherapy on November 19, 2019. It has been greater than 6 months since he last received immunotherapy and he did not progress while on the drug. The documentation support that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 Keytruda have been met. Therefore, we decided that the Plan has to pre-approve Keytruda.
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 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. The
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. You do require physical therapy and occupational
therapy services but based on the medical records provided you do not require an intensive inpatient
rehabilitation therapy program. There is concern that you will not be able to fully participate in and benefit
from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 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.