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

We decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy and biopsy (43239 and 43244).You asked the Plan to pre-approvean esophagogastroduodenoscopy and biopsy. You say that this is medically necessary.The Plan denied your request. The Plan says this is only necessary once every three years.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 an esophagogastroduodenoscopy and biopsy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the general consensus based on the guidelines is that a three-year follow-up is warranted to capture the infrequent progressive disease. A one-year follow-up is not considered necessary because there are no randomized, controlled trials supporting this interval. In this case, the risk of these procedures support a more conservative approach.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 esophagogastroduodenoscopy and biopsyhave not been met.Therefore, we decided that the Plan does not have to pre-approvean esophagogastroduodenoscopy and biopsy (43239 and 43244).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fora comprehensive oral exam (D0150), Bitewings (D0274) and resin-based composite (D2392) provided January 7 to January 15, 2020.You asked the Plan to pay for the dental services. You say that the services should be covered.The Plan denied your request. The Plan says while you have supplemental dental coverage, it is limited to certain preventative services such as cleaning and panoramic x-rays. The services at issue are not covered under your 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 pay fora comprehensive oral exam (D0150), Bitewings (D0274) and resin-based composite (D2392) provided January 7 to January 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on January 21, 2020 by an out of network (OON) provider.You asked the Plan to pay for lab work. You say that these services were provided because they were referred by a provider.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for lab work provided on January 21, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Neulasta.
You asked the Plan to pre-approve Neulasta. The Plan denied your request. The Plan says the enrollee does not have a risk of febrile neutropenia.
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 Neulasta. Our physician reviewer found that Neulasta is indicated for patients at high risk for neutropenic fever (greater than 20%). The regimen this enrollee is receiving is not considered to carry this level of risk and is being dose reduced. In addition, he has not received prior chemotherapy or been neutropenic or being treated for curative intent. Therefore, the service is not reasonable or 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 Neulasta have not been met. Therefore, we decided that the Plan does not have to pre-approve Neulasta.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on August 7, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services
cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering
physician's intent that the tests be performed. 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
drug testing services provided on August 7, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation.You asked the Plan to provide coverage foradditional routine transportation. You say that additional transportation is necessary.The Plan denied your request. The Plan says once this benefit is exhausted it cannot be extended.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 36 trips per year. The records show you have exhausted the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to provide coverage foradditional routine transportation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare will pay for an IRF admission when the services are reasonable and medically necessary. The patient must require an intensive and coordinated interdisciplinary approach to providing rehabilitation. The patient must need active and ongoing treatment by more than one therapy discipline. One of the therapies must be physical therapy or occupational therapy. The patient must need and be expected to actively participate in and to benefit from an intensive rehabilitation therapy program. This intensive rehabilitation therapy program generally consists of at least three hours of therapy per day at least five days per week. The patient does not need to be expected to achieve complete independence in self-care nor be expected to return to his or her prior level of functioning. The patient must need supervision by a rehabilitation physician. The physician must see the patient at least three days per week throughout the stay. You can find these rules in the Medicare Benefit Policy Manual, Chapter 1, Sections 110.2 and 110.2.5 and at 42 CFR Section 412.622.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the
enrollee.
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically
necessary. The Plan denied your request. The Plan says Medicare coverage criteria for transfer to an LTACH
are not met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician
reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was
correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested
LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found
based on the medical records, the enrollee does not require services at the proposed LTACH that are not
already available at the current acute care hospital. The records do not suggest that at least a 25 day stay at the
proposed LTACH would be needed to stabilize the enrollee. Based on the fact that the vitals are still not quite
stable enough for transfer and that acute care services are already being appropriately provided, the request for
LTACH services will be considered not medically necessary 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 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.You asked the Plan to pre-approve IRF care. You say that the enrollee requires frequent monitoring, and therapy.The Plan denied your request. The Plan says the enrollee does not need frequent physician visits, nursing care, or special equipment.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. His medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee may benefit from multiple therapies, such as physical and occupational therapy, but the documentation does not support that he requires this therapy an 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy evaluation rendered on August 7, 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 procedure code 97163 is not supported.
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 97163 is physical therapy evaluation, high complexity, typical time with patient and/or family 45 minutes. We find that CPT code 97163 is not supported in the medical record. Specifically, there is no documented physical therapy evaluation by a licensed physical therapist for the date of service at issue. The records show that the services were performed by a physical therapy assistant. 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 for the physical therapy evaluation rendered on August 7, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.
You asked the Plan to pre-approve Retacrit. You say that this is medically necessary. The Plan denied your
request. The Plan says this medicine is being dispensed to the enrollee by a pharmacy and is approved under
the enrollee's Part D benefit.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B,
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be
brought to the office for administration. Since the medication does not represent an expense to the physician
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that
the Plan does not have to pre-approve Retacrit.
Benefits for Retacrit may be available under Medicare Part D. Contact the Plan that administers Part D benefits
for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound care provided by a participating provider on February 25, 2020.
You asked the Plan to waive the copayment for wound care. You say that the doctor did not tell you that you were having a surgical procedure. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for outpatient surgery/in-network/outpatient hospital facility visits. You have been asked to pay a $250 copayment for wound care. Wound care is considered an outpatient surgery; therefore, the correct copayment has been applied. Wound care falls within the outpatient surgery/in-network/outpatient hospital facility visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for wound care provided by a participating provider on February 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe additional sound wave studies of the legs coded 93979 and 93971 and an additional unit of code 93970 and 93978.You asked the Plan to pre-approvethe additional sound wave studies of the legs. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says therequested 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 the additional sound wave studies of the legs. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a history of DVT and subsequent placement of a stent. Only one CPT code is needed in order to answer the question of clot progression. The codes requested duplicate the same study for bilateral already approved by the plan. There is no rationale for a unilateral procedure when bilateral is adequate.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 additional sound wave studies of the legs have not been met.Therefore, we decided that the Plan does not have to pre-approvethe additional sound wave studies of the legs coded 93979 and 93971 and an additional unit of code 93970 and 93978.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on January 9, 2020. You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not covered when provided by a chiropractor. The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on January 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Promethazine.
You asked the Plan to pre-approve Promethazine. The Plan denied your request. The Plan says the off-label use of this drug for the enrollee's condition is not medically accepted.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Promethazine. Our physician reviewer found that the enrollee has a diagnosis of nausea and vomiting related to acute kidney injury and hyperkalemia. The requested use of Promethazine is not FDA-approved for the enrollee's diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Therefore, Promethazine is not medically necessary for nausea due to acute kidney injury and hyperkalemia. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Promethazine have not been met. Therefore, we decided that the Plan does not have to pre-approve Promethazine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the E2300 power seat elevation system.You asked the Plan to pre-approve a power wheelchair with an E2300 power seat elevation system. You say that this equipment is medically necessary.The Plan denied your request. The Plan says while the power wheelchair and Medicare allowed accessories were approved, neither Medicare nor the Plan covers the E2300 power seat elevation system.The Plan must follow Medicare rules. Medicare does not cover the E2300 power seat elevation system. While this accessory may be appropriate for your use, neither the Plan nor Medicare provides coverage for this item. Therefore, we decided that the Plan does not have to pre-approve the E2300power seat elevation system.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate.You asked the Plan to pre-approve bone marrow aspirate. 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 bone marrow aspirate. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have longstanding low back pain and bilateral leg radiculopathy that is worsening. Bone marrow aspirate remains experimental for use in spinal fusion surgery. More research is needed. Therefore, you do 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 bone marrow aspirate have not been met.Therefore, we decided that the Plan does not have to pre-approve bone marrow aspirate.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for transfer are not met.
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 although improvement was noted during this acute care stay and vitals were generally stable, acute care appears to still be required due to a recent spike in white blood cell count. Continued antibiotics and monitoring are needed to ensure the enrollee is stable. There are no indications acute care services would be needed for at least 25 days to justify transfer to LTACH. The enrollee does not require services at the proposed LTACH that are not already available at the current acute care hospital. Medicare coverage criteria for transfer 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 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive oral exam (D0150) and panoramic x-rays
(D0330) provided February 25, 2020.
You asked the Plan to pay for the dental services. You say that you had to find a new dentist immediately as the
tooth you needed extracted was infected. You had called the plan prior to going to the second dentist and was
told that the services would be covered. The Plan denied your request. The Plan says these services exceeds the
benefit frequency limitation.
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. These services are once every
3 years. Records show that these services were provided July 16, 2020.
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 pay for
comprehensive oral exam (D0150) and panoramic x-rays (D0330) provided February 25, 2020.