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

We decided that the Plan does not have to pre-approve Abraxane (J9264) for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says the guidelines don't support this drug for treatment of stage IV nasopharyngeal
carcinoma.
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 the drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found Abraxane plus
nivolumab is not a standard of care. Abraxane, although often substituted for paclitaxel, is not FDA approved
or supported by major drug compendia for head and neck cancer. The combination is not FDA approved or
supported by major drug compendia or the medical literature. The service is not reasonable or medically
necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve Abraxane (J9264) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe personal protective equipment (D1999) provided on August 18, 2020.You asked the Plan to pay forthe dental service. You say that you appreciate the increased caution being taken due to Covid-19. You also say that you should not be responsible to pay for the additional charge for the additional time and materials that are needed because of it. You say that you are on a fixed income and cannot afford to pay this fee every time you go to the dentist as you do not know how much longer thiswill last.The Plan denied your request. The Plan says personal protective equipment (PPE) is not reimbursable under the supplemental benefit for this use from dental providers during Covid-19. The Plan also says that personal protective equipment is not listed as a covered service.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 personal protective equipment isnot among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe personal protective equipment (D1999) provided on August 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on December 4, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plandenied your request. The Plan says the claims were billed incorrectly.The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.We looked at the file and Medicare rules. The claimfor these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered on December 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services coded 64447 provided on April 20,
2020.
You asked the Plan to pay for the injection services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are included in another code billed for
the same date of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 64447 is not supported in the medical record. Specifically, this code is included in code
01402 also billed on this date of service. Therefore, this claim cannot be separately reimbursed. Based on this
information, we decided that Medicare rules for coverage of the injection services have not been met.
Therefore, we decided that the Plan does not have to pay for the injection services coded 64447 provided on
April 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe molecular genetic testing provided on June 27, 2020.You asked the Plan to pay forthe molecular genetic testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The molecular genetic testing at issue in this appealwas requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe molecular genetic testing provided on June 27, 2020.
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 you disagree with the denial. The Plan
denied your request. The Plan says the services are not medically necessary.
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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the
hospital on November 16, 2020 with hypoxic respiratory failure due to COVID-19 pneumonia. The
documentation does not support that the enrollee in this case requires services at the LTACH that are not
available at the acute care hospital where he is currently receiving care. The documentation does not support
that an additional 25 days of hospitalization are reasonably expected for the enrollee in this case. Consequently,
the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and
condition of the enrollee 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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 25, 2019, by an
out-of-network (OON) provider.
You asked the Plan to pay for the drug test. You say that you would like reconsideration because you perform
time sensitive, medically necessary testing. The Plan denied your request. The Plan says the member does not
have 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 medical services provided on September 25,
2019, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ConfirmMDX test provided to the enrollee on June 18, 2020.
You asked the Plan to pay for the test. You say that this should be covered based on Medicare guidelines. 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 pay for the test. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is noted to have an elevated PSA. Genetic testing was ordered alongside the performance of an initial
prostate biopsy. The long-term treatment/management plan was not known when the genetic testing was ordered, as the biopsy results were not yet known. There is no evidence that a second prostate biopsy was being considered and that the results of the genetic testing would be used to help determine whether the second prostate biopsy was necessary. As such, the coverage criteria for the performed genetic testing were not 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 the test have not been met. Therefore, we decided that the Plan does not have to pay for the ConfirmMDX test provided to the enrollee on June 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 6, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this caseand the referring physician arenotnetwork providers with the Plan. The Plandid not pre-approve the physician's services.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 physician's services provided on November 6, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for fundus photography with interpretation and report (92250), diagnostic eye exams (92012 and 92014) provided on June 1, 2020 through July 7, 2020.
You asked the Plan to pay for diagnostic eye exams and eye exam with photos. You say that there is a referral for the services provided. The Plan denied your request. The Plan says that prior authorization must be obtained for non-emergent services rendered by an out-of-network provider.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. The enrollee was referred for diagnostic eye exams and eye exam with photos by a Plan contract provider. The record contains a written referral approved by the Plan contracted provider. Under Medicare rules, this means diagnostic eye exams and eye exam with photos are considered approved by the plan. Therefore, we decided that the Plan has to pay for fundus photography with interpretation and report (92250), diagnostic eye exams (92012 and 92014) provided on June 1, 2020 through July 7, 2020.
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: Unfavorable

We decided that the Plan does not have to pre-approvethe CardioMEMS device (CPT Codes: C2624 and 33289).You asked the Plan to pre-approvethe CardioMEMS device. You say that the services are necessary.The Plan denied your request. The Plan says the services are considered experimental/investigational in the treatment of heart failure.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 CardioMems device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the current medical evidence is insufficient to support the use of an implantable pulmonary artery pressure sensing device in patients with heart failure and a low ejection fraction. Data on survival, long-term health benefits, safety, and quality of life are lacking. Therapy change based on data obtained from a CardioMEMS device has been demonstrated in only one trial to help reduce hospital readmission comparedto standard medical therapy. Concerns have been raised about potential bias in this trial, calling into question the results. Consequently, the efficacy of the CardioMEMS device is uncertain at this time, according to leading authorities and not recommended in current guidelines for the treatment of heart failure. The CardioMEMS device should be considered experimental / investigational 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 the CardioMems device have not been met.Therefore, we decided that the Plan does not have to pre-approvethe CardioMEMS device (CPT Codes: C2624 and 33289
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forout of network physician services provided to the enrollee.

You asked the Plan to pay for this service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 provide rin 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 thePlan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 21, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's services.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 physician's services provided on September 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.You asked the Plan to pre-approve IRF care. You say that the enrollee lives in an independent living apartment and because of COVID-19 the residents were put on lockdown for 8-9 months, which caused the enrollee to become inactive and lose a lot of muscle mass and strength. The Plan denied your request. The Plan says based on Medicare guidelines and the information the Plan hasabout the enrollee's condition;the enrollee does not meet the requirements.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for syncope and had surgical repair of an aortic aneurysm and insertion of a pacemaker. Your medical problems are stable. Thereare no identified problems that need inpatient medical management. 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. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program. 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 IRFadmission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo (J9299) for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the Medicare-approved sources don't support using this drug for stage IV nasopharyngeal carcinoma.
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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found although nivolumab is FDA approved for use in head and neck cancers it is approved a monotherapy. This enrollee is using nivolumab in combination with a taxane which is not FDA approved, supported by major drug compendia or the medical literature. The service is not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo (J9299) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided on May 13, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forphysician services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained.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 forphysician services provided on May 13, 2020, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee is in danger of not regaining maximal function.The Plan denied your request. The Plan says the requested IRF care 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 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on November 27, 2020 with a urinary tract infection (UTI). He was discharged to a skilled nursing facility on December 3, 2020. He does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require 15 hours per week of rehabilitative services and regular physician evaluation. The IRF services are not medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe destruction of benign lesions (17110)provided on August 18, 2020.You asked the Plan to pay forthe destruction of benign lesions. You say that you would like reconsideration because you did not have this many lesions removed and you are being overcharged by the provider.The Plan denied your request. The Plan says the seborrheic keratoses were cosmetic and not covered.The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable.  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 destruction of benign lesions. Our reviewer says that you had seborrheic keratoses destroyed on the billed date of service. Our reviewer found the removal of these lesions is considered cosmetic.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 destruction of benign lesions have not been met. Additionally, the record indicates that you were informed by the provider that this service would not be covered.Therefore, we decided that the Plan does not have to pay forthe destruction of benign lesions (17110) provided on August 18, 2020