Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Zarxio.
You asked the Plan to pre-approve Zarxio. You say that the services are necessary. The Plan denied your
request. The Plan says that based on the documentation provided, coverage criteria has not been met.
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 Zarxio. Our reviewer says that the
medication is medically necessary. Our physician reviewer found Filgrastim (Zarxio) is FDA approved for
patients at high risk for neutropenic fever. This enrollee has a low absolute neutrophil count after 1 cycle of
chemotherapy and is older than 65 years old combined with his chemotherapy his risk of neutropenic fever
with subsequent cycles is >20%. The service 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 Zarxio have been met. Therefore, we decided that the Plan has to pre-approve
Zarxio.
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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the intense multidisciplinary team is absolutely 
essential to identify and establish a base functional platform that will drive further recovery, reduce risk of 
medical and functional regression, and mitigate risk of returning to acute hospitalization. The Plan denied your 
request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for myocardial infarction and congestive heart failure. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The 
enrollee does require physical and occupational therapy but there is no documented need for an intensive 
rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a 
reasonable expectation that this enrollee 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve GeneSight Psychotropic Genetic Testing (81225, 81226, 81227, 81230, 81381).
You asked the Plan to pre-approve GeneSight Psychotropic Genetic Testing. You say that this is necessary for your doctor to understand what treatments can help you. The Plan denied your request. The Plan says the records do not show how the specific genetic testing requested will affect treatment.
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 GeneSight Psychotropic Genetic Testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found while the records show that you have not responded to at least one medication and are on multiple medications, increasing the risk of adverse effects, the records show that the ordering physician for this test is not board certified in psychiatry or neuropsychiatry. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of GeneSight Psychotropic Genetic Testing have not been met. Therefore, we decided that the Plan does not have to pre-approve GeneSight Psychotropic Genetic Testing (81225, 81226, 81227, 81230, 81381).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (0012M) provided December 8, 2020.
You asked the Plan to pay for the genetic testing. You say that the testing was medically necessary. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M for CxBladder are non-covered.
We looked at the file and Medicare rules. The service at issue is not covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (0012M) provided December 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure.

You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

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 an Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the intracept procedure remains experimental for low back pain. More research is needed to show safety and efficacy of the intracept 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 an Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the neck.

You asked the Plan to pre-approve a CT scan. You say that the enrollee has pain in her throat, dysphagia, and a globus sensation. The Plan denied your request. The Plan says the request is not indicated at this time.

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 a CT scan. Our physician reviewer found that there is no palpable mass, and the enrollee has no respiratory distress. The workup of this symptom would begin with endoscopic examination by an ear, nose and throat (ENT) specialist. The records state that ENT cannot see the enrollee soon. However, this does not constitute a reason for immediate CT examination. Therefore, the requested CT scan is not medically reasonable or 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 a CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the neck.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on March 24, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that the service was medically necessary and should be covered. The Plan denied your request. The Plan says the services were non-emergent. There were network providers available.
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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 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 an office visit (99214) provided on March 24, 2021 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87633) provided June 17, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says this test was not a covered service.

The Plan must follow Medicare rules. Medicare rules say that respiratory viral panels of 6 or more pathogens are non-covered.

We looked at the file and Medicare rules. The test at issue included more than 6 pathogens and is therefore non-covered. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (87633) provided June 17, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient cardiac rehabilitation services.
You asked the Plan to pre-approve outpatient cardiac rehabilitation services. You say that the records provided support the need for the requested cardiac rehabilitation services. The Plan denied your request. The Plan says the requested cardiac rehabilitation services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary cardiac rehab programs. The services must be provided in a doctor's office or an outpatient hospital setting. 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 outpatient cardiac rehabilitation services. Our reviewer says that cardiac rehab is not medically necessary. Our physician reviewer found the enrollee cannot walk far before getting shortness of breath and pain in her legs. She has severe claudication bilaterally. She is being treated with anti-hypertensives, statin medications but she has been unable to quit smoking. She has clinical evidence of peripheral vascular disease and prior interventional procedures done on her lower extremities due to pulse loss. The available documentation in the case file does not support that the coverage criteria for outpatient cardiac rehabilitation services have been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of outpatient cardiac rehabilitation services have not been met. Therefore, we decided that the Plan does not have to pre-approve outpatient cardiac rehabilitation services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a stay in a SNF on October 3 to October 8, 2020.
You asked the Plan to waive the copayment for a stay in a SNF. You say that you were not informed that your insurance had run out. The Plan denied your request. The Plan says the correct copayment was applied.
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 $55 copayment for each day for days 21 to 100 of a stay in a Medicare-certified SNF. You have been asked to pay a $300 copayment, or less than $55 for each day of days 21 to 26 of a stay in SNF. This means that you have been asked to pay less than or equal to 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 a stay in a SNF on October 3 to October 8, 2020.
Your complaint about receiving erroneous or incomplete information about your cost-sharing responsibility from the provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient medical services provided October 22, 2020.
You asked the Plan to pay for the outpatient medical services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim has denied for an incorrect diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that this claim includes an incorrect/invalid diagnosis code. Specifically, per the ICD-10, F41.91 is not a valid diagnosis code for the billed date of service. Based on this information, we decided that Medicare rules for coverage of the outpatient medical services have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient medical services provided October 22, 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 IRF care is needed to facilitate increased
independence and a return to home and community with improved quality of life. You say that the enrollee is
currently at high risk for falls, injury, and admission to acute care. The Plan denied your request. The Plan says
the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee's needs can be met at
a lower level of 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 in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee has a past medical history of rheumatoid arthritis, depression, and a throat mass and is living in an assisted living facility with symptoms of weakness and falling. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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: 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 without this it could cause you to have much slower progress. 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 in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 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 were admitted for a stroke and are receiving care at a skilled nursing facility. Your medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 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. 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 pre-approve hyaluronic acid injection
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says this is 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 the injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has osteoarthritis of the knees. The record indicates that she completed Synvisc in March. The request is for bilateral knee treatment. The enrollee has received treatment within the past 6 months on the knees.
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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve hyaluronic acid injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0261).
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the requested semi-electric hospital bed is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the medical necessity criteria have not been met for the requested device.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 a semi-electric hospital bed. Our reviewer says that the requested semi-electric hospital bed. Our physician reviewer found the documentation does not clearly reveal that patient's condition has failed positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The documentation does not support a need for frequent or an immediate change in body position or special attachments that cannot be fixed on an ordinary bed. The request for a semi-electric hospital bed is not medically necessary for this patient. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0261).