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

We decided that the Plan does not have to pay for the acute inpatient hospital care.

You asked the Plan to pay for the acute inpatient hospital care. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the inpatient hospital care provided was not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee presented to the emergency room with a headache, left sided facial numbness and per her husband, she had slurred speech. The enrollee also reported a facial droop and left sided weakness. Her labs were significant for hypokalemia and mild anemia. Per the physical exam note, the enrollee reported all symptoms had been resolved. The computed tomography (CT) scan of the head was negative, with a stable vp shunt and stable appearances of the ventricles. An electroencephalogram (EEG) and a Neurology consultation was recommended. The enrollee was then discharged. The review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights.

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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve Fluid flow procedure and MyOwn skin (CPT code(s): 15275, Q4206, Q4226), for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says that the services are considered experimental and investigational.

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 the services. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the services are medically necessary because the wound of facial skin is opened and needs a graft to heal. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pre-approve Fluid flow procedure and MyOwn skin (CPT code(s): 15275, Q4206, Q4226), for the enrollee.

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: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the moderate sedation anesthesia (99152).

You asked the Plan to pre-approve the moderate sedation. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says that the enrollee does not meet the medical necessity criteria for the requested sedation.

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 the moderate sedation. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case the claimant has anxiety that is worsened by injection. She has required conscious sedation during previous injection. She has obstructive sleep apnea. The ordering physician has provided a statement of necessity. The local coverage determination requirement for moderate conscious sedation or monitored anesthesia is satisfied by the documentation. The requested service is recommended. 

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 moderate sedation have been met. Therefore, we decided that the Plan has to pre-approve the moderate sedation anesthesia (99152).

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydralazine hydochloride tablet.

You asked the Plan to pre-approve Hydralazine hydochloride tablet. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.

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 Hydralazine hydochloride tablet.

Benefits for Hydralazine hydochloride tablet may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (99308) provided on February 6, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the nursing facility care. You say that the treatment received was medically necessary and the physician provided a statement of medical necessity and submit medical records to justify the reason for the enrollee's stay. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

Medicare rules say that plans can require enrollees to get care from network providers. 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. 

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 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 subsequent nursing facility care (99308) provided on February 6, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the coinsurance for the diagnostic colonoscopy (45378).

You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the coinsurance has been applied correctly to the service provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is no coinsurance, copayment, or deductible for a Medicare-covered colorectal cancer screening exam. Enrollee's pay a $0 copay for a biopsy or removal of tissue during a screening exam of the colon.

The Plan says you must pay a $112.65 coinsurance for the colonoscopy provided. Based on the Plan contract, however, you cannot be asked to pay this amount for a colorectal screening exam. The record shows that your physician ordered this service as a routine screening. You did not have any signs or symptoms that warranted testing. Additionally, no polyps were found or removed during this screening exam performed. Medicare specifically covers this procedure as a screening for those with high risk. Your history of polyps meets the Medicare definition of high risk, meaning that you are eligible for coverage of this procedure as a screening exam. Therefore, we decided that the Plan has to waive the coinsurance for the diagnostic colonoscopy (45378).

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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Udenyca.

You asked the Plan to pre-approve Udenyca. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested drug is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Udenyca. Our reviewer says that the documentation does support that the requested drug is medically reasonable and necessary. Our physician reviewer found the enrollee has small cell cancer of the colon. The enrollee was hospitalized for neutropenic fever. The enrollee has a risk of neutropenic fever of greater than 20% based on regimen, age, and prior history of neutropenic fever on this regimen. The documentation supports that the requested drug is FDA-approved for the enrollee's diagnosis. Therefore, the enrollee meets criteria for the requested drug. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Udenyca have been met. Therefore, we decided that the Plan has to pre-approve Udenyca.

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 pay for the intravenous (IV) Vitamin C infusions provided on September 14, 2020.

You asked the Plan to pay for the services provided. You say that the enrollee has a history of nutritional deficiencies. The Plan denied your request. The Plan says the clinical value and effectiveness of IV Vitamin C infusions have not been demonstrated in the peer-reviewed literature.

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 services provided. Our physician reviewer found that the enrollee is being treated for fatigue and immune deficiency disorder. The documentation does not support the clinical diagnosis or vitamin deficiencies. Therefore, the provided infusion services were not medically reasonable or necessary to treat 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 services provided have not been met. Therefore, we decided that the Plan does not have to pay for the intravenous (IV) Vitamin C infusions provided on September 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodic evaluation (D0180) and the pre-diagnostic test (D0460).

You asked the Plan to pay for the comprehensive periodic evaluation and the pre-diagnostic test. You say that the comprehensive oral evaluation, the comprehensive periodic evaluation, prophylaxis, the panoramic x-ray, and the bitewing x-rays should be covered, per your benefits. The Plan denied your request. The Plan says the comprehensive periodic evaluation is not listed as a covered service. The Plan says that pre-diagnostic test is not listed as a covered service either.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive periodic evaluation (D0180) and the pre-diagnostic test (D0460).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan has to pre-approve stereotactic body radiation therapy for the enrollee.

You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says that picture studies are not supported to guide this type of treatment.

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 the therapy. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found SBRT, delivering high fractional doses in 4-5 fractions is an established approach for the treatment of discrete lesions from cancer. SBRT systems use fiducials, bony anatomy or external markers as a coordinate system to map the delivery of radiation to increase the precision and accuracy of radiation delivery. Data suggest that SBRT would be superior to conventional palliative radiotherapy. The appeal letter addresses the need for SBRT in this enrollee. SBRT is within the accepted standards of care (as elucidated by the ASTRO model policy). It would meet the general medical necessity criteria by virtue of treatment furnished according to accepted standards of medical practice. 

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 therapy have been met. Therefore, we decided that the Plan has to pre-approve stereotactic body radiation therapy for the enrollee.

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).

You asked the Plan to pre-approve SNF care. You say that you need therapy and someone to watch you while you get stronger again. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (SNF) 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 admission to a Skilled Nursing Facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the intravenous infusion and injections provided by an out-of-network provider.

You asked the Plan to pay for the intravenous infusion and injections. You say that the services provided were medically necessary and payment should be made. The Plan denied your request. The Plan says this provider is not a network with the Plan.

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 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 intravenous infusion and injections provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on September 4, 2019.

You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the claim was filed untimely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the office visit was not filed until October 13, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the office visit provided on September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy (90832) rendered by the out of network (OON) provider on October 12, 2020.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service 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 this service. Therefore, we decided that the Plan does not have to pay for the psychotherapy (90832) rendered by the out of network (OON) provider on
October 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an abutment supported porcelain/ceramic crown (D6058).

You asked the Plan to pre-approve the abutment supported porcelain/ceramic crown. You say that you would like this service to be approved. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an abutment supported porcelain/ceramic crown (D6058).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the DecisionDx-Melanoma testing.

You asked the Plan to pay for the testing services. You say that the test is a covered Medicare benefit. The Plan denied your request. The Plan says the testing is not a Medicare covered service.

The Plan follows Medicare rules. Medicare rules say that molecular diagnostic tests 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 pay for the testing services. Our physician reviewer found that National Comprehensive Cancer Network (NCCN) guidelines states the ability of this test to accurately predict metastasis is limited as gene expression profiling with DecisionDx-Melanoma is not reliable. Therefore, the provided testing is not considered medically reasonable or 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 testing services have not been met. Therefore, we decided that the Plan does not have to pay for the DecisionDx-Melanoma testing.