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

We decided that the Plan does not have to pre-approve computed tomography (CT) services.
You asked the Plan to pre-approve the CT scan. You say that the records provided support the need for the requested CT scan. The Plan denied your request. The Plan says the guidelines support a chest x-ray in the initial evaluation of non-cardiac chest pain. The Plan says that the clinical information provided does not show that this criteria have been met.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CT scan. Our reviewer says that the documentation is insufficient to show that the requested CT scan of the chest is currently medically necessary or reasonable. Our physician reviewer found the enrollee is noted to have intermittent chest pain without respiratory symptoms. Physical examination notes normal heart sounds and clear breath sounds. There is no evidence of a recently abnormal chest x-ray. A cardiologist reportedly attributed the pain to residual effects of CPR. 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on January 2, 2020.
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 psychotherapy services provided on January 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health services May 27, 2020 forward. You asked the Plan to pre-approve continued inpatient mental health services. 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. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 continued inpatient mental health services. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee was to the acute inpatient psychiatric hospitalization on May 21, 2020 with Schizoaffective Disorder Bipolar Type and Alcohol Use Disorder. The enrollee presented with suicidal ideation, paranoia and auditory hallucinations. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as the enrollee was not showing any dangerousness to self or others, decreased auditory but no visual hallucinations and no abnormal behaviors. The documentation does not support that the enrollee meets criteria for the treatment in an acute inpatient mental health treatment beyond the date in question. The documentation supports that the enrollee could have been treated in a lesser restrictive setting as the enrollee was not showing any suicidal or homicidal ideation, being compliant with treatment while having decreased auditory but no visual hallucinations and was not showing any behaviors. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient mental health services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health services May 27, 2020 forward.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to pre-approve positioning seat cushion (E2605). We decided that the Plan does not have to pre-approve positioning back cushion (E2520). You asked the Plan to pre-approve positioning seat cushion (E2605). You say that please reconsider the decision and approve the cushions that were chosen to best meet her positioning needs. The Plan says that the records do not show that you have significant problems with poster therefore the special positioning cushions are not medically necessary. We decided that the Plan has to pre-approve positioning seat cushion (E2605). 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 positioning seat cushion (E2605). Our reviewer says that this enrollee partially meets the criteria. Our physician reviewer found the positioning (premiere) seat cushion may be justifiable based on preserving the skin flap. Paraplegics are prone to decubitus ulcers and once a flap surgery is performed, preservation of the flap is critical by providing appropriate seating cushions when the patients are unable to weight shift to prevent recurrence of pressure ulcers. Hence, the positioning seat cushion (E2605) is 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 positioning seat cushion (E2605) have been met. Therefore, we decided that the Plan has to pre-approve positioning seat cushion (E2605). We also decided that the Plan does not have to pre-approve positioning back cushion (E2520). 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 positioning back cushion (E2520). Our reviewer says that this enrollee partially meets the criteria. Our physician reviewer found for the requested seating cushions, there is no documentation either by the NP or PT that the enrollee has any significant postural asymmetries. All that was documented by the physical therapy in the seating clinic evaluation was poor trunk control. The poor trunk control comes from weak muscles from the paraplegia but asymmetry is totally different. There is no kyphosis or scoliosis documented if present. The positioning back cushion (E2520) is not meeting the criteria for coverage. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of positioning back cushion (E2520) have not been met. Therefore, we decided that the Plan does not have to pre-approve positioning back cushion (E2520).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network cardiologist.
You asked the Plan to pre-approve these services. You say that you prefer holistic approaches to medical care. The Plan denied your request. The Plan says the services are available from network providers.
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 care that cannot be provided by network providers. 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 referral to an out-of-network cardiologist.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ubrelvy.
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 self-administered drugs are not covered.
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 Ubrelvy.
Benefits for these services 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an in-lab sleep study for the enrollee.

You asked the Plan to pre-approve the study. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the study. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found coverage criteria for an attended PAP titration study are not met. It would be reasonable to start the patient on auto-titrating CPAP (APAP) at home and reassess with a followup visit. An attended PAP titration may be necessary if the APAP is not successful in treating the disordered breathing. An attended PAP titration study is 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 the study have not been met. Therefore, we decided that the Plan does not have to pre-approve an in-lab sleep study for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skin substitute.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the service is considered investigational and experimental.
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 requested services. Our physician reviewer found that you have a history of left lower extremity wounds. The requested skin substitute is not considered safe and effective, and otherwise medically reasonable. 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve skin substitute.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing rendered by an out-of-network provider on December 16, 2019. You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing was rendered 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 and that all genetic testing requires prior authorization. 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 genetic testing rendered by an out-of-network provider on December 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laser treatment/efudex.
You asked the Plan to pre-approve the procedure. You say that this is needed to return to a complexion before using fluoracil 5% cream. The Plan denied your request. The Plan says laser treatment of Rosacea is variable.
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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the first line anti-rosacea medications should be tried first. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve laser treatment/efudex.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cyclopentolate eye drops for the enrollee.
You asked the Plan to pre-approve this drug. The Plan denied your request. The Plan says that this is not
covered under Part B.
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 Cyclopentolate eye drops
for the enrollee.
Benefits for this drug 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery services provided on September 12, 2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the code is not documented as an independent procedure.
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 27066 is excision of bone cyst or benign tumor, wing of ilium, symphysis pubis, or greater trochanter of femur; deep (subfascial), includes autograft, when performed. We asked our coding 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 reviewer says that although an excision of bone cyst or benign tumor was documented in the medical record, the documentation does not validate that CPT code 27066 was performed as an independent procedure. CPT code 27134 - revision of total hip arthroplasty; both components, with or without autograft or allograft, was performed on the same date of service as CPT code 27066. Therefore, CPT 27066 is inclusive to the primary procedure of 27134. We looked at this coder'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 surgery services provided on September 12, 2019.
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 enrollee requires IRF care in order to get the necessary therapy to improve her condition. The Plan denied your request. The Plan says the records do not demonstrate the Medicare guidelines for coverage of IRF care have been met. The Plan says that the enrollee can safely receive the services needed in another setting.
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 does not require the intensity of services provided at an IRF. Specifically, 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve selective internal radiation therapy (SIRT) for the
enrollee.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary, as the enrollee has a
life-threatening condition. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the therapy. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found localized treatment options for liver metastases include resection, cryotherapy, radiofrequency ablation
embolization (radioembolization or chemoembolziation), and stereotactic radiation. Systemic therapy is the
standard treatment option for patients with liver metastases. Radioembolization can be considered medically
necessary for non-colorectal cancer liver metastases when no other acceptable standard therapy is available, or
no other therapy is likely to be effective (i.e. chemo-resistant tumors). There is a paucity of literature
supporting Y-90 microspheres in patients with liver metastases from lung cancer; nevertheless, Y-90
microspheres target the liver with an effective agent, and can be considered medically necessary when other
options are not available. However in this case, there is no documentation of whether the enrollee received
standard systemic therapy (before immunotherapy) or why standard systemic therapy would not be an option.
Radioembolization would be furnished in accordance with accepted standards of medical practice (based on
lack of documentation supporting need).
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 not been met. Therefore, we decided that the Plan does not
have to pre-approve selective internal radiation therapy (SIRT) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zolpidem Tartrate tablets.
You asked the Plan to pre-approve self-administered drugs. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
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 Zolpidem Tartrate tablets.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the  test provided to the enrollee on January 27, 2020.
You asked the Plan to pay for the test. You say that a proprietary pharmacogenomic assay used to help healthcare providers determine the correct medication for individual patients suffering from neuropsychiatric disorders. The Plan denied your request. The Plan says no attempt to obtain a prior authorization for this testing was made.
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 testing at issue in this case is not medically reasonable or necessary. Our physician reviewer found no provider records have been submitted for review. Therefore, there is no evidence to support that the provided service was medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition(s). 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 test provided to the enrollee on January 27, 2020.