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

We decided that the Plan does not have to pre-approve stereo-tactic body radiation therapy (SBRT).
You asked the Plan to pre-approve stereo-tactic body radiation therapy (SBRT). You say that the requested SBRT is medically necessary. The Plan denied your request. The Plan says the requested SBRT 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 stereo-tactic body radiation therapy (SBRT). Our reviewer says that the requested SBRT is not medically necessary. Our physician reviewer found for this enrollee, the consultation note (before abdominal MRI) suggests treating 1 lesion; the letter of appeal similarly advocates treating only 1 lesion. However the letter of appeal does not address that the abdominal MRI shows at least 4 liver metastases and that prior abdominal/pelvic CT revealed new (in 2018) adnexal and adrenal lesions. With multiple other sites of disease, the ASTRO model policy criteria of completely targeting all sites of disease is not met. The absence of PET avidity of these lesions (in a now outdated 1/17/20 PET/CT) does not necessarily mean that those lesions are ablated/controlled, and in fact systemic therapy would unlikely results in durable control of bulky tumors. While SBRT for widespread disease (which is the case in this enrollee) can perhaps be considered in some selected patients, there is no plausible, compelling reason for SBRT (over other forms of radiation) for this enrollee. SBRT would not be furnished within accepted standards of care, as the entire tumor burden cannot (and is not planned) to be encompassed, but rather only one liver metastases. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of stereo-tactic body radiation therapy (SBRT) have not been met. Therefore, we decided that the Plan does not have to pre-approve stereo-tactic body radiation therapy (SBRT).
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement in an assisted living facility (ALF).
You asked the Plan to pre-approve the ALF placement. You say that the enrollee is at risk of suffering mental
health issues due to stress from her living situation. You believe that ALF placement is needed for this and for
the enrollee's safety. The Plan denied your request. The Plan says there is no medical assessment provided of a
functional impairment requiring assistance. The Plan also says that the medical necessity of assisted living is
not required by the standard of care.
The Plan must follow Medicare rules. Medicare rules say that PACE plans must cover all services determined
necessary by the IDT to improve and maintain the enrollee's overall health status.
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 ALF placement. Our reviewer says
that the requested ALF placement is not shown to be reasonable and necessary based on Medicare/PACE rules.
Our physician reviewer found the enrollee suffered a pelvic fracture in September 2019 which resulted in acute
care and rehabilitation care. She was seen for a face-to-face visit on 02/22/2020. She was seen in the therapy
room. She was working out on a stationary bike. She was ambulating at least 100 feet to and from therapy with
her walker. She was independent with dressing per her physical therapist. She was able to stand long enough to
prepare her own meals. There had been no recent falls. The report references considering being very open to
coming to the rehabilitation center more often during the week. She was also felt to be better than her baseline
from when she was admitted.
The documentation does not support that the requested services are necessary and reasonable to meet the
enrollee's needs or to improve and maintain the enrollee's overall health status. The member is able to perform
all essential activities of daily living independently. There is no reason that she would need regular physical
assistance. Instrumental activities of daily living can be achieved through the use of homemaker services if needed. Assisted living facility placement is not 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 ALF placement have not been met. Therefore, we decided that the Plan does
not have to pre-approve placement in an assisted living facility (ALF).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay foreye surgery (67917 and 67700)(provided on March 20, 2019 by an out of network (OON) provider.You asked the Plan to pay foreye surgery. You say that these services were medically necessary.The Plan denied your request. The Plan says these services were not authorized.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 foreye surgery (67917 and 67700)(provided on March 20, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay formaxillofacial Computed Tomography (CT) imaging (70486) provided on September 5, 2019.You asked the Plan to pay forthe CT scan. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not preauthorized or emergent. There were in-network providers who could provide 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 inthis 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 formaxillofacial Computed Tomography (CT)imaging (70486) provided on September 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous lysis of epidural adhesions (62263).
You asked the Plan to pre-approve percutaneous lysis of epidural adhesions. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
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 percutaneous lysis of epidural adhesions. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested procedure has not been proven by research to be a helpful treatment for back pain. Catheter-based techniques for lysis of epidural adhesions, with or without endoscopic guidance, are considered investigational. Techniques used either alone or in combination include mechanical disruption with a catheter and/or injection of hypertonic solutions with corticosteroids, analgesics, or hyaluronidase. The review has determined that the requested items/services at issue in this case are not medically reasonable and 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 percutaneous lysis of epidural adhesions have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous lysis of epidural adhesions (62263).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the flow cytometry rendered to the enrollee on October 1, 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 code 88189 is not covered.
The Plan must follow Medicare rules. The rules say that an OPPS status indicator is assigned to every code to indicate whether it is payable. We looked at the file and Medicare rules. The provider submitted a claim for code 88189 (flow cytometry) under the OPPS payment system. This code has an OPPS status indicator of B and is not payable. Therefore, we decided that the Plan does not have to pay for the flow cytometry rendered to the enrollee on October 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 28, 2019.You asked the Plan to pay forthese 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 for eligible telehealth services, telecommunications systems substitutefor an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered on May 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fortrain of four testing (95999) provided on December 12, 2018You asked the Plan to pay fortrain of four testing. You say that this was medically necessary.The Plan denied your request. The Plan says payment of this service is bundled into other services.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 95999 is not supported in the medical record. Specifically, the use of unlisted CPT code 95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other interoperative neuromonitoring procedures.  Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met.Therefore, we decided that the Plan does not have to pay fortrain of four testing (95999) provided on December 12, 2018
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe vitamin D testing provided to the enrollee on October 30, 2019.You asked the Plan to pay forthe vitamin D testing. The Plan denied your request. The Plan says screening tests are not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The vitamin D testing at issue in this appealwas requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe vitamin D testing provided to the enrollee on October 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvespinal surgery, fusion of lower spine bones with removal of disc (22633, 63047, 22840, 22853, 20937, 20936).You asked the Planto pre-approvespinal surgery, fusion of lower spine bones with removal of disc. You say that the services are medically necessary.The Plandenied your request. The Plansaysmedical necessity has not been established. Therefore, coverage criteria has not been met.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 spinal surgery, fusion of lower spine bones with removal of disc. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records do not show evidence of spinal instability, fracture, or neurolgic deficit. Surgery for spinal fusion is not needed.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spinal surgery, fusion of lower spine bones with removal of disc have not been met.Therefore, we decided that the Plandoes not haveto pre-approvespinal surgery, fusion of lower spine bones with removal of disc (22633, 63047, 22840, 22853, 20937, 20936).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on August 1, 2019.You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan. 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. ThePlan did not pre-approve the service at issue. We found no exception that would requirethe Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for diagnostic radiology services provided on August 1, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea sleep study (95810).You asked the Planto pre-approvea sleep study. You say that a sleep study is medically necessary.The Plandenied your request. The Plansayscode 95811 was approved, so code 95810 is not necessary.The Plan follows Medicare rules. The rules state that effective for claims with dates of service on and after March 3, 2009, the Centers for Medicare & Medicaid Servicesfinds that the evidence is sufficient to determine that the results of the sleep tests identified below can be used by a beneficiary's treating physician to diagnose OSA.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 sleep study. Our reviewer says that a sleep study is not medically necessary at this time. Our physician reviewer found coverage criteria are not met for the sleep study with code 95810. This test duplicates the diagnostic portion of code 95811 (which has been approved), and is therefore not 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 a sleep study have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea sleep study (95810).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on August 20, 2019 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not preauthorized or emergent. There were in-network providers that could provide the services at issue.
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 (99214) provided on August 20, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on October 24, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that these services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained for these services. 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 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 October 24, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.

You asked the Plan to pre-approve Keytruda. You say that Keytruda is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of Keytruda.

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 Keytruda. Our reviewer says that Keytruda is not medically necessary at this time. Our physician reviewer found this patient has received several prior lines of therapy and is currently on cabometyx. The request is for the addition of Keytruda. This is not a standard regimen and is the subject of ongoing clinical trials. it is not FDA approved for this indication, supported by major drug compendia, or the medical literature. 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 Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services providedon September 18, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on September 18, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve Keytruda (J9271), Carboplatin (J9045), Paclitaxel (J9267), Ondansetron HCL (J2405), Dexmethasone Sodium Phosphate (J1100), Fosaprepitant (J1453), and Diphenhydramine HCL (J1200).You asked the Planto pre-approveKeytruda, Carboplatin, Paclitaxel, Ondansetron HCL, Dexmethasone Sodium Phosphate, Fosaprepitant, and Diphenhydramine HCL. You say that the drugs are medically necessary.The Plandenied your request. The Plansaysthe use of the drugs is not supported for the enrollee's condition.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 Keytruda, Carboplatin, Paclitaxel, Ondansetron HCL, Dexmethasone Sodium Phosphate, Fosaprepitant, and Diphenhydramine HCL. Our reviewer says that the requested drugs are not medically necessary at this time. Our physician reviewer found the requested use is not supported by major drug compendia. It is not reasonable and 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 Keytruda, Carboplatin, Paclitaxel, Ondansetron HCL, Dexmethasone Sodium Phosphate, Fosaprepitant, and Diphenhydramine HCL. have not been met.Therefore, we decided that the Plandoes not haveto pre-approveKeytruda (J9271), Carboplatin (J9045), Paclitaxel (J9267), Ondansetron HCL (J2405), Dexmethasone Sodium Phosphate (J1100), Fosaprepitant (J1453), and Diphenhydramine HCL (J1200).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper denture (D5110) and a lower denture (D5120).

You asked the Plan to pre-approve the dental items. You say that you have lost a lot of weight due to your depression. You say that your dentures no longer fit your mouth. You also say that you need new ones. The Plan denied your request. The Plan says dentures are covered once in a 60 month period. The Plan also says that the frequency limit has been reached.
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 and dentures are a covered service, the frequency limit of once every 60 months has been reached. The record shows that the Plan previously paid for dentures that you received on November 17, 2017. Therefore, we decided that the Plan does not have to pre-approve an upper denture (D5110) and a lower denture (D5120).