Persius/hicric huggingface dataset:
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 enrollee is ready for discharge and has been waiting for transfer.The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met.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 the enrollee is currently undergoing treatment at an acute care hospital (ACH) for an epidural abscess related to prior scalp/cranial surgery. Our physician reviewer found that the enrollee underwent drainage of the abscess and has received antibiotics. Our physician reviewer found thatthe enrollee was intubated/ventilated and subsequently received a tracheotomy and feeding tube. Our physician reviewer found that the enrollee has since been weaned from the ventilator to a tracheotomy collar. Our physician reviewer found that there is no advantage in transferring the enrollee to the LTACH and that the enrollee can remain at the current ACH until such a time that no acute services are required. Our physician reviewer found that the enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.You asked the Plan to pre-approve Keytruda. You say that this is medically necessary.The Plan denied your request. The Plan says that primary literature search did not reveal any studies supportive of Keytruda as monotherapy for first-line treatment of gastric cancer which satisfy our Off-Label use of FDA Approved Drugs Policy.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Keytruda. Our reviewer says that Keytruda is not medically reasonable and necessary for the enrollee in this case. Pembrolizumab is FDA approved for the treatment of recurrent locally advanced or metastatic gastric or gastroesophageal junction adenocarcinoma in patients whose tumors express PD-L1, as determined by an approved test,with disease progression on or after two or more prior lines of therapy including fluoropyrimidine and platinum-containing chemotherapy, and if appropriate, HER2/neu-targeted therapy. This patient has not received any prior therapy for her newly diagnosedmetastatic gastric cancer. Our physician reviewer found that the enrollee's condition does not meet criteria for Keytruda.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met.Therefore, we decided that the Plan does not have to pre-approve Keytruda for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
You asked the Plan to pre-approve the PET scan. You say that the case notes support the need for the requested PET scan. The Plan denied your request. The Plan says the enrollee's condition does not meet the rules for approval of the requested PET scan. The plan says that a chest PET scan is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that PET 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 the PET scan. Our reviewer says that the enrollee does not have an indication for which a PET scan can be covered at this time. Our physician reviewer found the records show the enrollee is requesting this study, despite no diagnosis of cancer and against the recommendation for a repeat chest computed tomography (CT) scan. 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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral, an out-of-network provider.You asked the Plan to pre-approve the referral. You say that this is medically necessary.The Plan denied your request. The Plan says these services are not urgent or emergent.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 pre-approve 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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve a referralto an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp (darbepoetin alfa) for the enrollee.
You asked the Plan to pre-approve Aranesp. The Plan denied your request. The Plan says the enrollee does not
have uncontrolled hypertension, and iron scores were normal.
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 Aranesp. Our physician reviewer found
that the enrollee's transferrin saturation level is less than 20%, indicating some element of iron deficiency.
Thus the enrollee does not meet criteria for Aranesp use.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have
to pre-approve Aranesp (darbepoetin alfa) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. The Plan denied your request. The Plan says there is no benefit in transferring you at this time.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 physician reviewer found that LTACHs are certified as acute care hospitals, and in general, do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support withsuctioning and tracheostomy care, surveillance laboratory studies, tube feeds, occupational and physical therapies. The documentation does not support that you require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve deep sedation services.You asked the Plan to pre-approv these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.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 deep sedation services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Decipher Prostate Cancer Assay.You asked the Plan to pre-approve the Decipher Prostate Cancer Assay.You say that the requested test is recommended to aid in deciding the best course of treatment.The Plan denied your request. The Plan says the information provided shows a Gleason score of 6 and 7 and Grade groups of 1 and 3. The plan says that, based on this information, the criteria for coverage of the requested test have not been met.The Plan follows Medicare rules. Medicare rules say that a Decipher Prostate Cancer Assay is only covered when certain coverage criteria have been met.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Decipher Prostate Cancer Assay. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has a Gleason score of 4 and 3, and is therefore not considered low or very low risk. Our physician reviewer found that the enrollee would be considered intermediate risk.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 Decipher Prostate Cancer Assay have not been met.Therefore, we decided that the Plan does not have to pre-approve a Decipher Prostate Cancer Assay.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent Injections (C9399).
You asked the Plan to pre-approve Dupixent. You say that the drug is medically necessary. The Plan denied
your request. The Plan says Dupixent is intended to be self-injected by the patient. Self-administered drugs of
this type cannot be covered under the Part B medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Dupixent Injections
(C9399).
Benefits for Dupixent 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 forphysician's services provided on May 21, 2019.You asked the Plan to pay forthe 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-approvethe servicesat 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 forphysician's services provided on May 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe genetic testing provided on August 22, 2019 by out of network provider,"the provider".You asked the Plan to pay forthe 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.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 careand 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 forthe genetic testing provided on August 22, 2019 by out of network provider, "the provider".
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit provided on June 26, 2019 by out of network provider, "the doctor".You asked the Plan to pay forthe office visit. 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.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 forthe office visit provided on June 26, 2019 by out of network provider, "the doctor".
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe endoscopic catheterization services provided on July 26, 2019.You asked the Plan to pay forthe endoscopic catheterization services. 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 payable.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 74328 is Endoscopic catheterization of the biliary ductal system, radiological supervision and interpretation.We find that CPT code 74328 is not supported in the medical record. Specifically, this claim is a duplicate of a charge considered on a previous claim It was previously processed and paid under a different claimto the same or different provider. It is inappropriate to submit multiple claims for the professional component (modifier 26) of the same diagnostic test as this service is performed once by a single provider. Based on this information, we decided that Medicare rules for coverage of the endoscopic catheterization services have not been met. Therefore, we decided that the Plan does not have to pay forthe endoscopic catheterization services provided on July 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 25, 2019.

You asked the Plan to pay for the physician's services. You say that that the enrollee was never told that this provider was out-of-network. You say the enrollee thought this plan was in addition to Medicare and not in place of Medicare and that whatever Medicare did not cover, then the Plan would cover. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from 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 services 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 physician's services provided on June 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forphysician's services and medical supplies provided on July 25, 2019.You asked the Plan to reimburse you forthe physician's services and medical supplies. You say that you returned the medical supplies that were not opened or used to the clinic and you would like reimbursement. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from theplan.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 reimburse you 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 and medical suppliesat issue. We found no exception that would require the Plan to reimburse you for these services.Therefore, we decided that the Plan does not have to reimburse you forphysician's servicesand medical supplies provided on July 25, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pay fora shoulder arthroscopy (29823-AS-RT) provided March 21, 2019.You asked the Planto pay fora shoulder arthroscopy. You say that you would like reconsideration based on the medical records provided.The Plandenied your request. The Plansaysthe billed service is not supported.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 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 a shoulder arthroscopy. Our reviewer says that the billed code is not supported in the medical record. Our physician reviewer found in the medical documentation provided, the operative report state, "To cite the operative report; "I proceeded with an extensive debridement in the glenohumeral joint with a combination of electrocautery and oscillating shaver." However, the degree of debridement is not described as required by the code.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 shoulder arthroscopy have not been met.Therefore, we decided that the Plandoes not haveto pay fora shoulder arthroscopy (29823-AS-RT) provided March 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician's services provided on June 5, 2019andJune 26, 2019.You asked the Plan to pay forthe 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 requireenrollees 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 servicesat 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 forphysician's services provided on June 5, 2019 and June 26, 2019.
Appeal type: Transportation
Decision: Partially Favorable

We decided that the Plan has to adjustthe copayment forthe ambulance transport services. We decided that the Plan does not have to waive the copayment forthe ambulance transport services.You asked the Plan to waive the copayment forthe ambulance transport services. You say that you were told that these services would be provided at no charge to you.The Plan says that the claims have been processedcorrectly per your plan benefits.
We decided that the Planhas to adjustthe copayment forthe ambulance transport services.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract withthe Plan says that enrollees must pay a $225 copayment for ambulance services.The Plan says you must pay a $275 copayment for each of the ambulance transport services. Based on the Plan contract, however, you cannot be asked to pay more than a $225 copayment for each of the ambulance transport services. Therefore, we decided that the Plan has to adjustthe copayment forthe ambulance transport services. 
We also decided that the Plandoes not have to waive the copayment forthe ambulance transport services.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 $225 copayment for the ambulance transport services.Therefore, we decided that the Plan does not have to waive the copayment forthe ambulance transport services