Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Percepta Bronchial Genomic Classifier test for the enrollee.

You asked the Plan to pre-approve the test. You say that the enrollee qualifies for this testing. 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 test. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this test assesses the risk of primary lung cancer in low and intermediate risk patients. It helps to reduce invasive procedures in patients with benign disease. The enrollee has been reassigned a high probability of malignancy, based on the size and nature of the nodule. The test is of no benefit in high risk patients. The test is indicated for patients with a smoking history; this enrollee never smoked. Finally, the pathology report indicates that a malignancy diagnosis has already been made from the transbronchial biopsies: marginal zone lymphoma. The Percepta test will not resolve the question of whether that diagnosis is correct.

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 pre-approve the Percepta Bronchial Genomic Classifier test for the enrollee.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve stereotactic body radiation therapy (SBRT).

You asked the Plan to pre-approve SBRT. You say that this will give the enrollee the best outcome. The Plan denied your request. The Plan says that the clinical value and effectiveness of SBRT in the setting of a subcutaneous left rectus abdominis muscle metastasis have not been demonstrated in the peer-reviewed literature.

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 SBRT. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found in the setting of a single metastasis with evidence of growth on serial imaging, and the absence of widespread disease seen on imaging, I believe that SBRT would be an accepted standard of care (per National Comprehensive Cancer Network (NCCN) guidelines and American Society for Radiation Oncology (ASTRO) model policy and therefore furnished in accordance with accepted standards of medical practice. A caveat would be that this is an atypical location for which SBRT would commonly be used.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SBRT have been met. Therefore, we decided that the Plan has to pre-approve stereotactic body radiation therapy (SBRT).

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultra-light weight wheelchair.

You asked the Plan to pre-approve an ultra-light weight wheelchair. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that the beneficiary must have a specialty evaluation that was performed by a licensed/certified medical professional (LCMP), such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features.

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 ultra-light weight wheelchair. Our reviewer says that the service is not medically necessary. Our physician reviewer found the provided records did not clearly and sufficiently support this request. There was no formal evaluation by the physician or physical therapy/ occupational therapy (PT/OT) describing the limits and abilities of the patient to help justify the ultra-lightweight wheelchair vs a regular 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 an ultra-light weight wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve an ultra-light weight wheelchair.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion or replacement of neurostimulator system for
treatment of central sleep apnea complete system or phrenic nerve stimulator.

You asked the Plan to pre-approve insertion or replacement of neurostimulator system for treatment of central
sleep apnea complete system or phrenic nerve stimulator. The Plan denied your request. The Plan says the
Medicare criteria for reasonable and necessary are not met as this device has not been shown to be safe and
effective in long term studies and there is a lack of evidence to support that this device is more effective than
current therapies for central sleep apnea.

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 insertion or replacement of
neurostimulator system for treatment of central sleep apnea complete system or phrenic nerve stimulator. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case.
Our physician reviewer found that implantation of a phrenic nerve stimulator is considered not medically
necessary. There is insufficient clinical evidence to support long-term efficacy and safety of this device in the
treatment of central sleep apnea (CSA), and it is considered investigational. In addition, this enrollee does not
appear to meet commonly accepted criteria for CSA, (i.e., at least 50% of apneic episodes central). The sleep
study of December 16, 2017 and the subsequent PAP titration showed that less than 50% of the breathing
events were central.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of insertion or replacement of neurostimulator system for treatment of central
sleep apnea complete system or phrenic nerve stimulator have not been met. Therefore, we decided that the
Plan does not have to pre-approve insertion or replacement of neurostimulator system for treatment of central
sleep apnea complete system or phrenic nerve stimulator.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve the additional trips. You say that this is medically necessary. The Plan
denied your request. The Plan says the benefit limit has been exceeded.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 24 one-way trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar magnetic resonance image (MRI).
You asked the Plan to pre-approve a magnetic resonance (eg, proton) imaging, spinal canal and contents,
lumbar; without contrast material (72148). You say that the enrollee needs an MRI because of lower back pain
and bilateral leg pain and burning. The Plan denied your request. The Plan says the same study has already
been approved for the enrollee under a different provider.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically
necessary.
We looked at the file, and Medicare rules. There is no information on the previously approved study, if it is the
same or if additional tests are needed according to the study results. Based on this information, we decided that
Medicare rules for coverage of a magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar;
without contrast material (72148) have not been met. Therefore, we decided that the Plan does not have to preapprove
a lumbar magnetic resonance image (MRI).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for maxillofacial prosthodontics.

You asked the Plan to pre-approve the referral. You say that there is a history of cancer of the right oropharynx which was treated in 2008. The Plan denied your request. The Plan says the requested provider is 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 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 an out-of-network referral for maxillofacial prosthodontics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is on Lantus Solostar 1 injection of eight units in the morning.

The Plan must follow Medicare rules. Medicare rules say that enrollees must be treated with multiple (three or more) daily administrations of insulin or a continuous subcutaneous insulin infusion pump.

You are only injected with insulin once per day in the morning. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that patients must be insulin-treated in order for a continuous glucose monitor to be covered.

There is no evidence of insulin treatment in the records. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (G0480) rendered by the out-of-network
(OON) provider on April 15, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, 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.

The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal.

The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for
this service. Therefore, we decided that the Plan does not have to pay for the drug testing (G0480) rendered by
the out-of-network (OON) provider on April 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care could be received 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 in the Medicare rules section. 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for altered mental status and acute kidney injury. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (81529) rendered by the out-of-network
(OON) provider on March 24, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, 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.

The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal.

The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for
this service. Therefore, we decided that the Plan does not have to pay for the laboratory service (81529)
rendered by the out-of-network (OON) provider on March 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the cardiology office visit you had on
February 23, 2021.
You asked the Plan to waive the deductible for the office visit. You say that the doctor billed for both an office
visit and a transthoracic echocardiogram (TTE). You said that you did not have a TTE, so the cost sharing
should be waived. The Plan denied your request. The Plan says it agrees that you were charged incorrectly for a
TTE, so they have waived the cost sharing associated with that test. However, the Plan says that you were
assessed a deductible for the cardiology office visit appropriately.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $203 deductible that applies to specialist visits.
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $203 deductible that
applies to specialist visits. This cost sharing is a contractual obligation that had not been met at the time the
office visit was received on February 23, 2021. Therefore, we decided that the Plan does not have to waive the
deductible for the cardiology office visit you had on February 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection (64414) provided on January 18, 2021.
You asked the Plan to pay for the injection. You say that you would like reconsideration based on the records
submitted. The Plan denied your request. The Plan says the documentation submitted does not support the
service billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We asked our coder 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 injection. Our reviewer says that CPT code 64416 does
not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records operative
note does not include documentation that an injection, anesthetic agent and/or steroid; brachial plexus was
ordered/performed on January 18, 2021, therefore, this service cannot be verified.
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 injection have not been met. Therefore, we decided that the Plan does not
have to pay for the injection (64414) provided on January 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Injectafer 750mg/15ml vial 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 that the laboratory values do not currently demonstrate iron deficiency anemia.

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 the drug. Our reviewer says that the
requested services are medically reasonable and necessary. Our physician reviewer found Injectafer is FDA
approved for the treatment of iron-deficiency anemia (IDA) in adults with intolerance to oral iron or
unsatisfactory response to oral iron such as this enrollee. Iron stores are low with a ferritin of 12. 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 the drug have been met. Therefore, we decided that the Plan has to pre-approve
Injectafer 750mg/15ml vial for the enrollee.

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 pay for the office visit (99214) rendered by the out-of-network (OON) provider on February 19, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, 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. 

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal.

The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on February 19, 2021.