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

We decided that the Plan does not have to pre-approveinjections services.You asked the Plan to pre-approveinjections services. You say that you would likethe plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.The Plan follows Medicare rules. Medicare rules say that injection services are only covered for certain indications.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 injections 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 has low back pain. The enrollee has had diagnostic medical branch blocks and radiofrequency ablation at lower lumbar levels which have providedthe enrollee with sustained pain relief. However, the enrollee received dual diagnostic medical branch blocks injections at L1 and L2 level and the enrollee received only one diagnostic medical branch block at T12 and L1. The documentation does not support that the enrollee has met criteria of the LCD as the enrollee did not have at least 80% pain relief from dual diagnostic medical branch blocks at the requested levels.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of injections services have not been met. Therefore, we decided that the Plan does not have to pre-approveinjections services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), each additional intraoral periapical x-ray (D0230), and two extractions (D7140 x2) provided on June 30, 2020 by an OON provider.You asked the Plan to pay forthe problem focused limited oral evaluation, intraoral periapical x-rays, and extractions. You say that you were not aware that you went to an OON provider.The Plan denied your request. The Plan says the claim paid correctly at the OON level.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, you are responsible for the difference between the billed amount and allowed amount.Therefore, we decided that the Plan does not have to pay forthe problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), each additional intraoral periapical x-ray (D0230), and two extractions (D7140 x2) provided on June 30, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental surgery (41899), face bone graft (21210), lower jawbone graft (21215), and formation of direct or tubedpedicle (15574) provided on May 20, 2019.You asked the Plan to pay forthe dental surgery, face bone graft, lower jawbone graft, and formation of direct or tubed pedicle. You say that these services were medically necessary due to the enrollee's genetic condition.The Plan denied your request. The Plan says although the services billed are non-dental codes, the requested services are not medical in nature.Medicare generally does not cover dental services. The Plan follows the same rule.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 dental surgery, face bone graft, lower jaw bone graft, and formation of direct or tubed pedicle. Our reviewer says that the services provided are dental and not medical in nature. Our physician reviewer found the case as presented does not present as treatment of a primarily medical condition or injury scenario and as such coverage is not available for the requested procedures.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services thatare not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay forthe dental surgery (41899), face bone graft (21210), lower jawbone graft (21215), and formation of direct or tubed pedicle (15574) provided on May 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the service is medically necessary.The Plan denied your request. The Plan says services can be obtained at a lower level of care.The Plan must follow Medicare rules. The rulessay 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 there are no complex nursing or rehabilitation needs nor does the enrollee require an intensive rehabilitation therapy program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Specifically, services can be obtained at a lower level of care. This means IRF is not medicallynecessary or reasonable.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a referral to a dermatologist.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says that there has been no trial and failure of conservative treatments.
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 referral. Our reviewer says that the
requested referral is considered medically reasonable and necessary in this case. Our physician reviewer found
the "wart" that grew back may represent a skin cancer lesion.
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 referral have been met. Therefore, we decided that the Plan has to preapprove
a referral to a dermatologist.
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 pay forthe initial nursing facility visit (99305) provided on January 25, 2019.You asked the Plan to pay forthe initial nursing facility visit. You say that these services were provided in good faith and were medically necessary.The Plan denied your request. The Plan says this claim was filed past the allowed 12-month timeframe.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for the initial nursing facility visit was not filed until September 3, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe initial nursing facility visit (99305) provided on January 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided September 12, 2020, to September 13, 2020.You asked the Plan to pay foracute inpatient hospital care. You say that the inpatient care was medically necessary.The Plan denied your request. The Plan says inpatient care was not medically necessary and care could have been provided within the observation length of stay.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the member presented to the emergency department on September 12, 2020, with increased abdominal pain, distension, nausea and vomiting. The member was admitted to the hospital; he improved rapidly with nasogastric suction by the next day and the member's condition improved. He tolerated an oral diet and was discharged home with outpatient follow-up. The review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span twomidnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay forthe acute inpatient hospital care provided September 12, 2020, to September 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forprophylactic dental care (D1110) received from an out of network provider on September 16, 2020.You asked the Plan to pay forprophylactic dental care. You say that the dentists in the Plan network lack the experience and work ethic you need to maintain your health.The Plan denied your request. The Plan says rules for payment havenot been met.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 prophylactic dental care when received from a contracted provider. We looked at the case file and Medicare rules. In this case, the provider from whom you received prophylactic dental care is not a contracted provider. Based on this information, we decided that the Plan's rules for coverage of prophylactic dental care have not been met.Therefore, we decided that the Plan does not have to pay forprophylactic dental care (D1110) received from an out of network provider on September 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forpathology services provided on September 23, 2020 by an out of network (OON) provider.You asked the Plan to pay forpathology services. You say that you were told that authorization was not needed.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is also out-of-network.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 had network providers available who could have provided 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 forpathology services provided on September 23, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveKeytruda and Famotidine.You asked the Plan to pre-approvethe requested drugs. The Plan denied your request. The Plan says the drug regimen is not being prescribed for a medically-accepted indication.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 requested drugs. Our physician reviewer found that the requested use of the drug regimen is not FDA-approved for the enrollee's diagnosis. The drug regimen is used as a first line treatment for stage III if they are not a candidate for definitive chemoradiation or surgery,andhave aPD-L1greater than or equal to 1%. This enrolleehad chemoradiation and PD-L1 is 0. The notes states the regimen is being using for maintenance based on high TMB. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The use is not listed as not indicated, not supported or not recommended in any of the compendia. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary 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 requested drugs have not been met.Therefore, wedecided that the Plan does not have to pre-approveKeytruda and Famotidine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvedental services (D2950) for the enrollee.You asked the Plan to pre-approvethe services. You say thatthis is medically necessary.The Plan denied your request. The Plan says this is not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.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-approvedental services (D2950) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on February 20, 2020.You asked the Plan to payforthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that payment for code 85060 may only be made if rendered in an inpatient hospital setting.We looked at the file and Medicare rules. The file shows that procedure code 85060 was billed with place of service code11 for an office setting. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered on February 20, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe Ascent injection for the enrollee.You asked the Planto pre-approvethe injection. You say that this is medically necessary.The Plandenied your request. The Plansaysthe clinical value and effectiveness of Ascent injection in the setting of osteoarthralgia of the knee have not been demonstrated in the peer-reviewed literature.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 injection is not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental and investigational procedure. Therefore, the request is deemed 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 Plandoes not haveto pre-approvethe Ascent injection 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. You say that the service is medically necessary.The Plan denied your request. The Plan says the service is not medically necessary.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there are no services at the LTACH thatthe patient requires that are not already available and covered at the current facility.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 havenot been met. Specifically, services can be obtained at the enrollee's current level of care. This means that LTACH is not medically necessary or reasonable.Therefore, we decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cytopathology, in situ hybridization (eg, FISH), urinary tract specimen with morphometric analysis, 3-5 molecular probes, each specimen; manual (CPT Code 88120) provided on October 11, 2019.
You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request. The Plan says these services are not authorized because molecular genetic screening testing panel is not a Medicare benefit for the diagnoses as listed on the claim and are done for screening purposes.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Diagnosis: R31.21 - Asymptomatic microscopic hematuria. These services are not authorized because molecular genetic screening testing panel is not a Medicare benefit for the diagnoses as listed on the claim and are done for screening purposes. Medicare non-coverage applies to both contracted and non-contracted providers and cannot be overridden by plan directed care. Any and all codes on this claim are denied, and in addition, previous payments to this provider for this member are subject to recoupment. Therefore, we decided that the Plan does not have to pay for cytopathology, in situ hybridization (eg, FISH), urinary tract specimen with morphometric analysis, 3-5 molecular probes, each specimen; manual (CPT Code 88120) provided on October 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Continuous Glucose Monitor (K0553).You asked the Plan to pre-approvethe Continuous Glucose Monitor. You say that the Continuous Glucose Monitor is medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules saythat a Continuous Glucose Monitor is covered for enrollees who are insulin-treated with multiple (three or more) daily injections of insulin.We looked at the file and Medicare rules. The record does not show that the enrollee is treated with multiple daily insulin injections. Based on this information, we decided that Medicare rules for coverage of the Continuous Glucose Monitor have not been met.Therefore, we decided that the Plan does not have to pre-approvea Continuous Glucose Monitor (K0553)
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. You say that the service is medically necessary.The Plan denied your request. The Plan says the service is not medically necessary or reasonable.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there are no services at the LTACH that the patient requires that are not already available and covered at the current facility.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. Specifically, services can be obtained at current level of care. This means that LTACH is not reasonable or necessary.Therefore, we decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller upgrade, expandable controller
harness, and electronic connection.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that an expandable controller with harness is covered
for specific indications and an electronic connection is included in power tilt and recline seating and power leg
elevation systems.
We looked at the file and Medicare rules. The services at issue are an expandable controller with harness and
electronic connection. The electronic connection is already available in the approved power tilt and recline
seating and power leg elevation systems. The expandable controller and harness are not needed to control the
power systems through a joystick. Based on this information, we decided that Medicare rules for coverage of
these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an
expandable controller upgrade, expandable controller harness, and electronic connection.