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

We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection.
You asked the Plan to pre-approve epidural injection. You say that you are appealing with medical records. The
Plan denied your request. The Plan says the denial of authorization for this service is correct, because the
enrollee did not receive long-lasting benefits from the previous epidural and there is no clinical information
which supports this service.
The Plan follows Medicare rules. Medicare rules say that epidural injections are only covered for certain
indications. Response to each epidural injection should be determined prior to determining the value of a repeat
epidural and the specific methods used for subsequent epidurals.
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 epidural injection. Our reviewer says
that the enrollee does not meet the Medicare criteria for the requested epidural. Our physician reviewer found
the prior epidural injection did not result in more than 50% pain relief; therefore, coverage criteria are not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of epidural injection have not been met. Therefore, we decided that the Plan does
not have to pre-approve a lumbar epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out-of-area injections.
You asked the Plan to pre-approve the out-of-area services. You say that you need the shots to get through negative symptoms. The Plan denied your request. The Plan says the care is foreseen, and not a covered benefit.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. We looked at the file, and Medicare rules. The requested services do not appear to be urgent or emergent. The need for services was known prior to leaving the service area. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve out-of-area injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health services.
You asked the Plan to pre-approve the inpatient mental health services. You say that the records provided support the need for the requested level of care. The Plan denied your request. The Plan says inpatient behavioral health services are not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the inpatient mental health services. Our reviewer says that the criteria for coverage of inpatient behavioral health services have not been met. Our physician reviewer found the enrollee was admitted to the acute inpatient psychiatric hospitalization on January 15, 2020 with Major Depressive Disorder, Recurrent, Severe without 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. The enrollee was compliant with treatment. 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. It did appear that the records were supervised and evaluated by a physician. 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 inpatient mental health services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health services.
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 the enrollee would heal faster in an LTACH. The Plan denied your request. The Plan says the enrollee's needs can be met in the current facility.
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 the enrollee requires rehabilitation and monitoring which could be performed at the current acute care facility until breathing support is successfully weaned. As weaning appears to be difficult currently, the enrollee would not be stable enough for transfer to a lower level of care yet. However, transfer to LTACH would also not be appropriate as the enrollee's needs appear to be met at the current acute care facility. The enrollee does not require services at the LTACH that are not already available and covered by the current acute care hospital. Therefore, this request for transfer to the proposed LTACH will be considered not medically necessary based on the documentation provided. 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: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided December 26, 2018.  You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services at issue have already been paid.
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 find that CPT code 99285 is not supported in the medical record. Specifically, Evaluation and Management service, 99285, was billed with another Evaluation and Management service on the same day. Medicare and plan rules only allow payment for the single evaluation and management service with the highest allowable Medicare reimbursement amount. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services provided December 26, 2018.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation trips over 50 miles.
You asked the Plan to pre-approve routine transportation trips over 50 miles. You say that there are no providers within fifty miles of your home. The Plan denied your request. The Plan says trips of over 50 miles are not covered by the Plan.
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 routine transportation trips up to 50 miles. We looked at your request, the records in the case file, and the rules. The trips you are requesting are 59 miles long, which exceeds the 50 mile limit. Based on this information, we decided that the Plan's rules for coverage of routine transportation trips over 50 miles have not been met. Therefore, we decided that the Plan does not have to pre-approve routine transportation trips over 50 miles.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a high frequency chest wall oscillation device (HFCWOD) provided May 29, 2019 to July 29, 2019.
You asked the Plan to pay for a HFCWOD. You say that please review the attached appeal to prove medical necessity with office notes and process the claim for payment. The Plan denied your request. The Plan says the services does not meet coverage requirements.
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 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 a HFCWOD. Our reviewer says that the coverage criteria for a HFCWOD was not met. Our physician reviewer found this enrollee has COPD, oxygen dependent. Bronchiectasis is listed as a diagnosis on the order, but the records do not include a chest CT scan confirming this diagnosis. The enrollee does not have cystic fibrosis or neuromuscular disease. There is a question of aspiration as a cause for the pneumonia. The HFCWOD is considered not medically necessary because the enrollee does not have a persistent, productive cough, and because the diagnosis of bronchiectasis is not documented on imaging. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a HFCWOD have not been met. Therefore, we decided that the Plan does not have to pay for a high frequency chest wall oscillation device (HFCWOD) provided May 29, 2019 to July 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99215) provided on August 29, 2019 by the out
of network provider.
You asked the Plan to pay for an office visit. You say that you are appealing claim payment denial for services
rendered to the Plan's member on date of service August 29, 2019. The Plan denied your request. The Plan says
this doctor is a non-participating provider. The Plan says they did not authorize any services for
this non-participating provider. The Plan says that there are multiple in-network providers within 30 miles of the members residence that could have rendered the services. The services are not considered urgent/emergent in nature.
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 an office visit (99215) provided on August 29,
2019 by the out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra.
You asked the Plan to pre-approve Xiidra. The Plan denied your request. The Plan says this is not covered under your medical plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xiidra.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zemplar.
You asked the Plan to pre-approve Zemplar. You say that the requested Zemplar is medically necessary. The Plan denied your request. The Plan says the requested Zemplar is not medically necessary.
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 Zemplar. Our reviewer says that the requested Zemplar is not medically necessary. Our physician reviewer found Zemplar is in clinical trials for this use. This review relates to a request for use of Zemplar in combination with Abraxane and Gemzar for neoadjuvant treatment of resectable pancreatic cancer. Zemplar is not FDA approved for the requested use. The drug is not supported for use in pancreatic cancer in any of the CMS approved compendia. This reviewer found no supporting citations in a PubMed review. This reviewer notes there are several ongoing clinical trials of the drug in varying combinations in both metastatic and non-metastatic pancreatic cancer listed on Clinicaltrials.gov. There is one 15 patient pilot study, NCT02030860, that is listed as completed. No results are posted. Therefore the requested use is investigational. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zemplar have not been met. Therefore, we decided that the Plan does not have to pre-approve Zemplar.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 22853, CPT 20936) provided on March 12, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes 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 22853 is "Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure)". We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use of CPT codes 22853 and 20936 is not supported by the records provided. Our coding reviewer found that the medical records provided do not contain documentation of a Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure), therefore the service cannot be verified. Additionally, Medicare has given CPT code 20936 a status code of B ( Bundled Code). CPT 20936 is bundled with CPT 22612 which was billed on the same claim and paid. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (CPT 22853, CPT 20936) provided on March 12, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial imaging for the enrollee.
You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your request. The Plan says a service must be deemed reasonable and medically necessary to qualify for coverage.
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 imaging. Our reviewer says that the requested imaging is not considered medically reasonable and necessary in this case. Our physician reviewer found based on the records, the enrollee has some coronary risk but no clear documented chest pain or dyspnea, a normal cardiovascular physical exam, a reportedly abnormal electrocardiogram (not provided or further detailed) and a normal echocardiogram. In this circumstance the documentation does not support the medical necessity for nuclear stress testing, since there are no documented symptoms concerning for ischemia, no documented ischemic electrocardiographic changes and no left ventricular dysfunction on echocardiography. 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 imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve myocardial imaging for the enrollee.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a kidney transplant.
You asked the Plan to pre-approve a kidney transplant. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says that the requested services are not medically necessary.
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 a kidney transplant. Our reviewer says
that the requested services are considered medically reasonable and necessary in this case. Our physician
reviewer found you have end stage renal disease secondary to diabetes and several chronic conditions including
coronary artery disease. You are getting an evaluation for renal transplant. You have had a right heart
catheterization and have World Health Organization Group 2 pulmonary hypertension. This is quite common
and is not to be confused with primary pulmonary hypertension. This would not be considered a
contraindication itself to a renal transplant. You meet criteria for a kidney transplant evaluation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a kidney transplant have been met. Therefore, we decided that the Plan has to
pre-approve a kidney transplant.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex interspinous and/or interlaminar device for the enrollee.
You asked the Plan to pre-approve Vertiflex interspinous and/or interlaminar device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. 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 Vertiflex interspinous and/or interlaminar device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee had back pain with right lower limb pain. The enrollee has tried and failed, non-steroidal therapy, opiates, 15 visits of physical therapy, epidural steroid injection, bracing, chiropractic care, acupuncture, and home exercises. The requested device is considered experimental. More research is needed to show safety and efficacy. Therefore, the enrollee does not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex interspinous and/or interlaminar device have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex interspinous and/or interlaminar device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve debridement of open wound including topical applications, wound assessment and instructions for ongoing care for the enrollee.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that wound care is covered when specific criteria are met. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no actual documentation of an examination identifying a sacral ulcer on this enrollee. The documentation does not sufficiently support that a wound exists or show what type of treatment, including what type of provider, would be medically necessary to treat the wound. The requested services are not reasonable or medically necessary at this time based on the submitted records. We looked at this physician's review, the file, and Medicare rules. 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 debridement of open wound including topical applications, wound assessment and instructions for ongoing care for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 15, 2019 by the out of
network provider.
You asked the Plan to pay for outpatient lab work. You say that you would like this claim to be reprocessed
and approved for payment. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that there are in-network providers available for the services in question.
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 the medical services provided on August 15, 2019
by the out of network provider.