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 you need more days at the facility.The Plan denied your request. The Plan says your needs could be met in another 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 based on the provided medical records the current acute care hospital is able to provide all of the services the patient requires.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services (CPT 99152) provided on October 30, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service cannot be verified.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 99152 is " Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older".We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use of CPT code 99152 is not supported by the records provided. Our physician reviewer found that the enrollee was given continuous hemodynamic monitoring and 22 minutes of moderate sedation were given. CPT guidelines requires an independent trained observer to assist in the monitoring of the enrollee's level of consciousness and physiological status. The documentation does not report an independent trained observer was present during procedure.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay for the anesthesia services (CPT 99152) provided on October 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.
You asked the Plan to pre-approve facet joint injections. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of authorization for the requested facet joint injections is correct, because these services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered when the enrollee meets certain, specific criteria. 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 facet joint injections. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested facet joint injections. Our physician reviewer found although pain was present intermittently for more than 3 months with failure of conservative care and the average pain level is reported as 8/10, there was no evidence of facet joint mediated pain. The most recent physical findings also included non-tender facet joints of the cervical spine. Pain related to the prior fusion surgery is likely to be the primary source of pain, according to the records and documentation, and not facet joint pain specifically as required by Medicare criteria. The documentation shows that a prior medial branch block was used on the cervical spine, but there was no report stating that at least 80% relief of pain or at least 50% improvement in the ability to perform previously painful movements and activities of daily living (ADLs) was achieved. Therefore, the requested facet joint injections are not considered medically reasonable and 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 facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Computed Tomography (CT) scan of the knee.You asked the Plan to pre-approve CT scan. You say that you are appealing based on medical necessity.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this test is not medically necessary.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 CT scan. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested CT scan. Our physician reviewer found there is no specific clinical rational for the requested CT scan of the knee. The results of the right knee X-Rays have not been provided. There is no documentation indicating that the enrollee is unable to have more standard imaging, such as Magnetic Resonance Imaging (MRI).We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CT scan have not been met.Therefore, we decided that the Plan does not have to pre-approve a Computed Tomography (CT) scan of the knee.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay forgenetic testing provided on September 24, 2019.You asked the Plan to pay forthe genetic testing. You say that you would like reconsideration as this service was medically necessary.The Plan denied your request. The Plan says that this service is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the genetic testing. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the Cxbladder momitor test significantly outperformed FDA approved urine based monitoring tests. It supports Cx bladder monitor as a confirmatoey adjunct to cytology.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 genetic testing have been met.Therefore, we decided that the Plan has to pay forgenetic testing provided on September 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve stereotactic body radiotherapy (SBRT) for prostate adenocarcinoma.
You asked the Plan to pre-approve the SBRT. You say that the clinical information provided supports the need for SBRT. The Plan denied your request. The Plan says this type of treatment is not supported for the cancer type the enrollee has.
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 SBRT. Our reviewer says that the requested SBRT is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has metastatic prostate cancer to the bone. SBRT will not give a survival benefit and external beam radiation therapy can be used for painful metastasis. 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 SBRT have not been met. Therefore, we decided that the Plan does not have to pre-approve stereotactic body radiotherapy (SBRT) for prostate adenocarcinoma.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (pembrolizumab) injections.
You asked the Plan to pre-approve the Keytruda treatment. You say that this treatment is necessary and should be approved. The Plan denied your request. The Plan says the enrollee's cancer does not have features which allow the use of Keytruda.
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 the Keytruda treatment. Our reviewer says that the requested treatment with Keytruda is not considered reasonable and necessary for this enrollee. Our physician reviewer found the enrollee has been treated with multiple agents for metastatic prostate cancer. This drug is only for use in cancers with dMMR/high levels of microsatellite instability (MSI-H) and overexpression of programmed cell death receptor 1 ligand (PD-L1), which may indicate potential benefit from therapies that target programmed cell death receptor 1 (PD-1). The enrollee's cancer does not have these features so the use of this medication 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 Keytruda treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda (pembrolizumab) injections.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Carboplatin (J9045), Paclitaxel (J9267), Bevacizumab (J9035), TECENTRIQ (J9022), and Fosaprepitant (J1453). You asked the Plan to pre-approve Carboplatin, Paclitaxel, Bevacizumab, TECENTRIQ, and Fosaprepitant. You say that the requested medications are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met. 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 Carboplatin, Paclitaxel, Bevacizumab, TECENTRIQ, and Fosaprepitant. Our reviewer says that the medication is medically necessary. Our physician reviewer found this enrollee received immunotherapy in 2016 for metastatic disease but was switched to another agent when she was found to have an epidermal growth factor receptor (EGFR) mutation and not for progression. There is medical literature to support use of immunotherapy months to years after initial immunotherapy with response. The service is reasonable and 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 Carboplatin, Paclitaxel, Bevacizumab, TECENTRIQ, and Fosaprepitant have been met. Therefore, we decided that the Plan has to pre-approve Carboplatin (J9045), Paclitaxel (J9267), Bevacizumab (J9035), TECENTRIQ (J9022), and Fosaprepitant (J1453).
Appeal type: Inpatient Hospital
Decision: Favorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information to the Independent Review Entity (IRE). You can find this information in the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Grievance Manual, Section 50.12.1. If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on July 8, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says the enrollee's PCP did not refer the enrollee for these 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 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 lab services provided to the enrollee on July 8, 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 you live alone but cannot safely be home alone,
move independently, or perform activities of daily living. The Plan denied your request. The Plan says the
denial of authorization for IRF service is correct.
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 you do not require the intensity of services provided at an IRF. Specifically, you are
not shown to require 15 hours per week of rehabilitative services and regular physician evaluation. Your care
needs can be met at a lower level of care such as Skilled Nursing Facility (SNF) or outpatient rehabilitation.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One for the enrollee.You asked the Plan to pre-approve Gel-One. The Plan denied your request. The Plan says that the enrollee does not have a history of failure, contraindication, or intolerance to the remaining formulary alternatives: Durolane, and Gelsyn-3.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Gel-One. Our reviewer says that Gel-One is not medically reasonable and necessary for the enrollee in this case. The documentation does not support trial and failure of Durolane and Gelsyn. The documentation does not support that Durolane and Gelsyn would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Gel-One.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gel-One have not been met.Therefore, we decided that the Plan does not have to pre-approve Gel-One for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.
You asked the Plan to pre-approve a total electric hospital bed. You say that the enrollee needs a total electric hospital bed. The Plan denied your request. The Plan says total electric hospital beds are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 81173 provided on November 11, 2019.
You asked the Plan to pay for CPT code 81173. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Medicare says genetic testing procedures submitted under CPT code 81173 will be denied automatically as not medically necessary. Therefore, we decided that the Plan does not have to pay for CPT code 81173 provided on November 11, 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 was previously able to ambulate with a cane or walker and is now unable to. You say that you would like the chance to get the enrollee back to his prior level of function. You say that the enrollee's provider believes that the aggressive therapy an IRF can provide would benefit the enrollee. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee could receive care in an alternate 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 was medically stable with no evidence of a need for supervision by physical medicine and rehabilitation physician. There is no evidence of a need for acute rehab nursing care. The enrollee is at a very low functional level. The enrollee may benefit from further physical therapy and occupational therapy, but does not require an intensive therapy program. An IRF admission is not medically necessary based on the enrollee's current functional status and medical stability. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transit kit for the power wheelchair.You asked the Plan to pre-approve a transit kit. The Plan denied your request. The Plan says durable medical equipment are covered for use in the home.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Therefore, we decided that the Plan does not have to pre-approve a transit kit for the power wheelchair.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the brain (70551).
You asked the Plan to pre-approve an MRI of the brain. You say that you need an MRI and have waited three months The Plan denied your request. The Plan says this is not necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the brain. Our reviewer says that the requested MRI is not shown to be medically necessary. Our physician reviewer found sufficient medical information was not provided to support the requested MRI, therefore, medical necessity cannot be established. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the brain have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the brain (70551).