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

We decided that the Plan has to pay for a laparoscopy (45400 and 57425) provided on January 27, 2020.
You asked the Plan to pay for the laparoscopy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the submitted medical records do not contain sufficient detail to support the billed charges.
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 codes 45400 and 57425 are supported in the medical record. Specifically, the admission date and electronic signature date indicate that this procedure could have only been performed on the billed date of service. There is no information to indicate that this recorded date of service is incorrect. Based on this information, we decided that Medicare rules for coverage of the laparoscopy have been met. Therefore, we decided that the Plan has to pay for a laparoscopy (45400 and 57425) provided on January 27, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ER visit provided on February 22, 2020.You asked the Plan to waive the copayment forthe ER visit. You say that your copayment would have been $0 if you were able to go to your primary care physician. You say that this is what you expect to pay for this care.The Plan denied your request. The Plan says the copayment applied correctly.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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records show that you were treated in the ER. This means that you have been asked to pay 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 forthe ER visit provided on February 22, 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 the services are necessary.The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there are no services at the LTACH that you require that are not already available and covered at the current setting. You can effectively get the needed care staying where you are and when stable for discharge, you could go to a lower level of care. Therefore, this request for LTACH services will be considered not 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
You asked the Plan to pre-approve these 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 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 not medically necessary. Our physician reviewer found the enrollee has left upper lobe poorly differentiated adenocarcinoma of the lung diagnosed in 2017. Keytruda is FDA approved for the treatment of patients with non-small cell lung cancer as monotherapy for metastatic non-first line disease if the PD-L1 is greater than or equal to one percent. It has no off-label indications. It is not likely to be effective for patients with a PD-L1 of zero percent and 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup for teeth #1, 2, 16, and 32 (D2950) and a crown for teeth #1 and 2 (D2750).You asked the Plan to pre-approve core buildup for teeth #1, 2, 16, and 32and a crown for teeth #1 and 2. You say that the services are necessary since you are barely eating for fear that your teeth will break.The Plan denied your request. The Plan says the covered benefit has been exhausted and the other requested serviceis not a covered benefit.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. The Plan covers 2 crowns per calendar year and does not cover core buildup under any circumstances.We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of core buildup for teeth #1, 2, 16, and 32 and a crown for teeth #1 and 2 have not been met. The plan covers 2 crowns per calendar year. The record shows that you received 2 crowns on June 24, 2020. This means that you not eligible for health plan coverage of 2 crowns at this time.Therefore, we decided that the Plan does not have to pre-approvecore buildup for teeth #1, 2, 16, and 32 (D2950) and a crown for teeth #1 and 2 (D2750).
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 IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different 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 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 based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require skilled physical therapy and occupational therapy but based on the medical records provided the enrollee does not require treatment in an intensive rehabilitation therapy program. 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 pay forthe lab services provided on August 20, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe services provided. You say that the test may be ordered to aid in the diagnosis of new or recurrent bladder cancer.The Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers, and authorization for certain services.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 atissue. 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 forthe lab services provided on August 20, 2019 by an out of network (OON) provider..
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the implantation of a neurostimulator (63650, L8680, 95970).
You asked the Plan to pre-approve the implantation of a neurostimulator. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for these services.
The Plan follows Medicare rules. Medicare rules say that SCS may be covered for the relief of chronic intractable pain under the above listed circumstances. 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 implantation of a neurostimulator. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee does not have a compatible diagnosis for chronic back pain. 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 implantation of a neurostimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve the implantation of a neurostimulator (63650, L8680, 95970).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy.
You asked the Plan to pre-approve proton beam therapy. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 proton beam therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has prostate cancer. Use of proton beam RT is expanding as more proton beam treatment centers open. However, there are no randomized trials comparing proton beam therapy with photon therapy or brachytherapy in enrollees with clinically localized prostate cancer. A systematic review of the available evidence from ASTRO on efficacy and toxicity concluded that outcomes were similar with proton beam therapy and intensity-modulated radiation therapy (IMRT) using photons but did not demonstrate a benefit for the proton beam approach. Clinical practice guidelines form the American Urological Association (AUA)/American Society for Radiation Oncology (ASTRO)/Society of Urologic Oncology (SUO)/American Society of Clinical Oncology (ASCO) conclude that proton beam therapy offers no clinical advantage over other forms of definitive treatment. Therefore, the enrollee does not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Shoulder elbow wrist hand orthosis (L3960) provided December 19, 2019.
You asked the Plan to pay for the orthosis. You say that please see the attached medical records which prove the medical necessity of the item and process the claim for payment. The Plan denied your request. The Plan says the billed supply code cannot be verified
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 orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation in the case file does not support that the requested shoulder/arm orthosis was medically reasonable and necessary for the enrollee in this case. A physical examination of the shoulder would
reasonably be required to adequately assess whether the shoulder/arm orthosis was medically necessary for an enrollee. The documentation does not support that the orthosis was medically reasonable and necessary for the enrollee in this case, as there is insufficient documentation of a shoulder problem and a credible physical examination of the shoulder. 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 orthosis have not been met. Therefore, we decided that the Plan does not have to pay for Shoulder elbow wrist hand orthosis (L3960) provided December 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveRepatha.You asked the Plan to pre-approveRepatha. 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-approveRepatha.Benefits for Repathamay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveaMyoPro Motion G custom myoelectric upper extremity orthosis (L8702).You asked the Plan to pre-approvethe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.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 fileand apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested robotic orthosis is not proven to be more beneficial for treatment of the patient's medical condition/function of hemiparesis after stroke than any available standard therapy. The requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member.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 orthosis have not been met.Therefore, we decided that the Plan does not have to pre-approvea MyoPro Motion G custom myoelectric upper extremity orthosis (L8702).
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 services are medically necessary.The Plan denied your request. The Plan says 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 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.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: 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 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. 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-approveacute 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 the requested IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is status post revision left total hip arthroplasty. As of 7/7/2020, nausea is improving. She has ongoing pain control needs. She is hemodynamically stable and non-toxic. Functionally, is stand-by assist/minimal assist for care. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lesser level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a lesser level of care. In this case, the member is mostly stand-by assist/minimal assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted period. An IRF intensity is not warranted.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forcomprehensive oral evaluation -new or established patient (D0150), intraoral -complete series of radiographic images (D0210), prophylaxis -adult (D1110) and oral hygiene instructions (D1330) provided on February 13, 2019.You asked the Plan to pay forthe dental services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says the services are not a covered benefit under the 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. These services/dental codes are not listed in your EOC as covered benefits; therefore, the services are not covered.Therefore, we decided that the Plan does not have to pay forcomprehensive oral evaluation -new or established patient (D0150), intraoral -complete series of radiographic images (D0210), prophylaxis -adult (D1110) and oral hygiene instructions (D1330) provided on February 13, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvespine surgery (22551, 22845, 20931).You asked the Plan to pre-approvespine surgery. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 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 spine surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no correlation between any documented exam and imaging. There is no documentation of myelopathy or radiculopathy. There is no spinal instability. Surgery is not needed.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spine surgery have not been met.Therefore, we decided that the Plan does not have to pre-approvespine surgery (22551, 22845, 20931).