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

We decided that the Plan does not have to pre-approve Zarxio for the enrollee. You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy guidelines were not followed. 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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the records provided do not reveal any evidence to suggest the enrollee had tried and failed Neupogen or Nivestym. Based on the clinical information provided, there was no suggestion that Neupogen or Nivestym would be less effective and/or add more risk for the enrollee. Neupogen and Zarxio are essentially clinically equivalent and should have the same risks and benefits for this enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Zarxio for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for nursing facility care provided on August 28, 2019.
You asked the Plan to pay for nursing facility care. You say that this provider is recognized by Medicare. The
Plan denied your request. The Plan says that this service was billed by a non-physician practitioner who cannot
bill directly for services rendered.
The Plan must follow Medicare rules. Medicare rules say that direct billing and payment for NP services may
be made to the NP.
We looked at the file and Medicare rules. In this case, the Plan denied the services at issue because a nonphysician
practitioner cannot bill Medicare directly. However, Medicare rules are clear that a NP may bill and
get paid directly. The Plan denial is not substantiated. Therefore, we decided that the Plan has to pay for
nursing facility care provided on August 28, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the Intraoral complete series of radiographic images provided on
August 14, 2019.
You asked the Plan to pay for these services. You say that The Plan denied your request. The Plan says that
that you received a full mouth series x-ray on December 1, 2014.
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 full mouth xrays
every 5 years.
We looked at the file and Medicare rules. You had full mouth x-rays in December of 2014, however this was
prior to your enrollment with the plan. Therefore, the plan has not covered full mouth x-rays for you since
you've become a member of the plan. Based on this information, we decided that the Plan's rules for coverage
of these services have been met. Therefore, we decided that the Plan has to pay for the Intraoral complete series
of radiographic images provided on August 14, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay forthe services provided to enrollee on August 23, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says that fraudulent services were billed.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan contends that the billed services were misrepresented, and that the documentation indicates that fraud and abuse has been committed. While there may be evidence of fraudulent billing in this case, the plan has not clearly pointed to any evidence supporting its denial.Therefore, we decided that the Plan has to pay forthe services provided to enrollee on August 23, 2019.Ifthe Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Doxorubicin HCL Liposome (Q2050) for the enrollee.You asked the Plan to pre-approve the drug. You say that this is medically necessary.The Plan denied your request. The Plan says for Part B coverage, Doxil is subject to step therapy.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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the review has determined that the Plan requires a trial of anthracycline-based therapy before they will approve the requested drug. The Plan's required drug is not likely to be less effective and/or likely have adverse effects for the enrollee. The review indicates that the enrollee has not had a trial of anthracycline-based therapy. The requested Doxorubicin HCL Liposome (Q2050)is not medically necessary and reasonable 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 drug have not been met.Therefore, we decided that the Plan does not have to pre-approve Doxorubicin HCL Liposome (Q2050) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve an L3 kyphoplasty procedure.
You asked the Plan to pre-approve the L3 kyphoplasty procedure. You say that the integrity of the spinal canal
is in question at the L2 level and, therefore, stabilization is appropriate. The Plan denied your request. The Plan
says that the treating radiologist and neurologist did not recommend this procedure in their documentation. The
Plan says that the hospitalist that was treating the enrollee stated that kyphoplasty was not in the enrollee's best
interest. The Plan says that the clinical information provided does not indicate that the enrollee has an
osteoporotic fracture.
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 pre-approve the L3 kyphoplasty procedure. Our
reviewer says that an L3 kyphoplasty procedure is considered medically reasonable and necessary in this case.
Our physician reviewer found the records show that there is a pathologic cancer fracture at L3. There is plan
for minimally invasive stabilization surgery with L3 kyphoplasty. The L3 kyphoplasty should be approved for
this cancer fracture. It is the standard of care for stabilization of cancer lumbar compression fractures when
combined with MIS stabilization surgery. This is well shown in the cancer literature for pain reduction.
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 L3 kyphoplasty procedure have been met. Therefore, we decided that the
Plan has to pre-approve an L3 kyphoplasty procedure.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of care at the inpatient psychiatric hospital.
You asked the Plan to pre-approve the continuation inpatient psychiatric care. You say that the enrollee is not stable for discharge. You say that the enrollee continues to require acute care due to ongoing internal preoccupation, disorganization, and psychosis. The Plan denied your request. The Plan says the outpatient level of care is appropriate.
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 the continuation inpatient psychiatric care. Our reviewer says that the requested level of care is not medically necessary. Our physician reviewer found the enrollee was admitted to the acute inpatient psychiatric hospitalization on May 7, 2020 with bipolar disorder, depression, and severe psychotic features. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time for the dates in question, as she did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations, delusions or behaviors including aggression. The enrollee was compliant with treatment while not showing any acute threats to safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as she did not have dangerousness to self or others but was compliant with her treatment.
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 continuation inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuation of care at the inpatient psychiatric hospital.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the three additional intraoral periapical x-rays provided by an OON provider on December 2, 2019.You asked the Plan to pay for the additional intraoral periapical x-rays. You say that you were not aware that this provider was not in-network.The Plan denied your request. The Plan says intraoral x-rays have a frequency limit of one per calendar year, which had been exhausted. The Plan also says that services performed by an out-of-network provider are not covered because your healthcare plan does not have out-of-network benefits.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, intraoral x-rays are limited to one procedure per calendar year. The record shows that you received a first intraoral periapicalx-ray on December 2, 2019 and your intraoral x-rays benefit was then exhausted. The contract also says that services provided out-of-network are not covered.Therefore, we decided that the Plan does not have to pay for the three additional intraoral periapical x-rays provided by an OON provider on December 2, 2019. Your complaint about the provider being dishonest is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for supplies and materials (except spectacles), provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered (CPT Code 99070) purchased on May 23, 2019 from an out-of-network provider.You asked the Plan to pay for the DME. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met.Medicare requires specific evaluations be done prior to approval of the device you are requesting. A phone call was made to the provider on February 13, 2020 and they stated that they had not submitted an order for the scooter you independently purchased (May 2019). You have not completed the necessary evaluations for approval of this device. Therefore, your request is not medically necessary under your Medicare and your plan.Therefore, we decided that the Plan does not have to pay for supplies and materials (except spectacles), provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered (CPT Code 99070) purchased on May 23, 2019 from an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for hospital services provided April 11, 2018 by the provider.
You asked the Plan to pay for the hospital services. You say that the services were medically necessary. The Plan denied your request. The Plan says that they were unable to make a coverage decision within the required timeframe.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan did not provide the medical records for this case to the IRE for review. The plan failed to provide documentation showing why the claim was initially denied. Therefore, we decided that the Plan has to pay for hospital services provided April 11, 2018 by the provider.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) scan services.
You asked the Plan to pre-approve the CT scan. You say that the requested CT scan is needed to give the best care to this patient. You say that the enrollee has a grade 2/3 endometrial cancer and did not get chemotherapy. You say that the enrollee is considered higher risk. The Plan denied your request. The Plan says the CT of the abdomen and pelvis is not medically necessary due to the lack of documentation that there is a concern for recurring metastasis disease. The Plan says that the requested CT does not meet the required criteria for coverage.
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 requested CT scan is not medically necessary. Our physician reviewer found the request is for surveillance imaging for an enrollee with a stage IA endometriod endometrial cancer that completed treatment in November of 2018. Surveillance imaging is not a standard of care. Imaging should be guided by enrollee symptoms, risk assessment, and clinical concern for recurrent or metastatic disease. Indications may include abnormal physical exam findings such as vaginal tumor; palpable mass or adenopathy; and new pelvic, abdominal, or pulmonary symptoms. There is no documentation that the enrollee has any signs or symptoms to suggest recurrence. 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) scan services.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay forthe services provided to enrollee on August 23, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the billed services were fraudulent.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan contends that the billed services were misrepresented, and that the documentation indicates that fraud and abuse has been committed. While there may be evidence of fraudulent billing in this case, the plan has not clearly pointed to any evidence supporting its denial.Therefore, we decided that the Plan has to pay forthe services provided to enrollee on August 23, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay forthe services provided to enrollee on August 26, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the billed services were fraudulent.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan contends that the billed services were misrepresented, and that the documentation indicates that fraud and abuse has been committed. While there maybe evidence of fraudulent billing in this case, the plan has not clearly pointed to any evidence supporting its denial.Therefore, we decided that the Plan has to pay forthe services provided to enrollee on August 26, 2019.If the Plan does notagree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services rendered to the enrollee on September 30, 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 that procedure codes 80372, 80373 and 83992 are not valid for Medicare purposes.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that billed procedure codes 80372, 80373 and 83992 have a status indicator of I and are not valid for Medicare purposes. While this is true, this is for billing under the Physician Fee Schedule. The file shows that these services are laboratory services billed by a laboratory and are subject to the Laboratory Fee Schedule. There is no documentation submitted by the Plan to support that these services are not payable as billed. Therefore, we decided that the Plan has to pay for the laboratory services rendered to the enrollee on September 30, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve paravertebral facet joint injections.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your
request. The Plan says the requested injections are not indicated at this time.
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 injection. Our reviewer says that the
requested injections are not considered medically reasonable and necessary in this case. Our physician reviewer
found your physical exam is negative for cervical facet signs. There is no cervical MRI imaging. The requested
procedure is not medically reasonable or 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 injection have not been met. Therefore, we decided that the Plan does not
have to pre-approve paravertebral facet joint injections.