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

We decided that the Plan does not have to pay for the drug testing rendered on September 17, 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 the claim was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 11 for an office setting; however, the file shows that the specimen was obtained in an outpatient rehabilitation setting and should have been billed with POS code 57. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on September 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injections provided on March 6, 2020.
You asked the Plan to waive the coinsurance for the Part B injections. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received Part B injections on the date of service at issue in this appeal. The Plan says that the correct coinsurance has applied per your contract with the Plan.
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 20% coinsurance for Medicare Part B prescription drugs. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received Part B injections on March 6, 2020. You have been asked to pay a 20% coinsurance for the Part B injections, totaling $472. The Part B injections fall within the Medicare Part B prescription drugs 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 coinsurance for the Part B injections provided on March 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant at surgery services coded as 11643, 21235 and 14060 provided January 3, 2020.
You asked the Plan to pay for assistant at surgery services. You say that you respectfully disagree with this denial decision as services rendered are in fact medically necessary. The Plan denied your request. The Plan says the claim was billed with CPT codes which are not valid for assistant at surgery services.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 11643, 14060, 21235. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for assistant at surgery services have not been met. Therefore, we decided that the Plan does not have to pay for the assistant at surgery services coded as 11643, 21235 and 14060 provided January 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that inpatient rehab level of intensive therapy exceeds the member's need. 
 
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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
patient is medically stable with an uncomplicated right below knee amputation and no evidence of need for 
supervision by physical medicine and rehab physician or need for acute rehab nursing care. Functionally given 
he needs prosthetic training, the enrollee needs physical therapy (PT) but does not require IRF level of 
therapies. The patient may benefit from further PT but does not require an intensive therapy program. Our 
physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 
 
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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pembrolizumab (Keytruda). 
 
You asked the Plan to pre-approve Keytruda. The Plan denied your request. The Plan says the enrollee does not 
meet guidelines for the requested drug treatment. 
 
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 Keytruda. Our physician reviewer 
found that Keytruda was requested to treat esophagogastric cancer with PDL1 of TPS 3%. She has progressed 
on two previous platinum based regimens. The drug is not FDA approved for this indication. The drug is 
supported for esophagogastric cancer, Adenocarcinoma, locally advanced or metastatic, PD-L1 expression, 
after failure of 2 or more fluoropyrimidine- and platinum- containing therapies. This citation does not specify 
the degree of positivity nor the test required. In addition, the NCCN Compendium notes the use as preferred 
third-line or subsequent therapy as a single agent for esophageal and EGJ adenocarcinoma with PD-L1 
expression levels by CPS of greater than or equal to 1. The review did not find a correlation of CPS and TPS. 
The use is not listed as not indicated, not supported or not recommended in any of the compendia. 
 
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 Pembrolizumab (Keytruda).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI scan. 
 
You asked the Plan to pre-approve an MRI scan. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested MRI is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI scan. Our reviewer says that 
the documentation does not support that the Our physician reviewer found you have had several week history 
of back pain and are receiving an evaluation by Neurosurgeon. The documentation does not support weakness 
or radicular pain. The documentation shows that you have had symptoms of fairly short duration. The 
documentation does not support any indication for an MRI. Therefore, you do not meet criteria for the 
requested MRI. 
 
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 MRI scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an MRI scan.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ramucirumab and Docetaxel.
You asked the Plan to pre-approve Ramucirumab and Docetaxel. You say that the best course of action is to
proceed with taxotere and cyramza every 21, days. The Plan denied your request. The Plan says Ramucirumab
with or without a taxane is recommended only for treatment of adenocarcinoma of the esophagus, not
squamous cell carcinoma.
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 Ramucirumab and Docetaxel. Our
physician reviewer found that Ramucirumab and Docetaxel was requested to treat metastatic squamous cell
cancer of the esophagus. The requested treatment is not FDA approved. The requested treatment is not
supported in any of the CMS approved compendia. This reviewer did not find any supporting citations in a
PubMed search. The use is not listed as not indicated, not recommended or not supported in any of the
compendia. The documentation does not support that the requested drugs are safe and effective and otherwise
reasonable and necessary for this enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Ramucirumab and Docetaxel have not been met. Therefore, we decided that the
Plan does not have to pre-approve Ramucirumab and Docetaxel.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the
enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says it is not reasonable and necessary to receive inpatient SNF level therapy for an
enrollee who is functioning at their physical baseline.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is 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 admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to
safely and effectively provide medically necessary and reasonable treatment in a SNF. She does not have
complex wound care or other ongoing SNF level SN need. She does not require skilled therapy services with
the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide
medically necessary and reasonable treatment in a SNF. She does not require skilled nursing or skilled therapy
services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, this enrollee
does not require the necessary services on an inpatient basis, in a skilled nursing facility setting.
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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee arthroscopy meniscectomy. 
 
You asked the Plan to pre-approve knee arthroscopy meniscectomy. 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 knee arthroscopy meniscectomy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee presents with a long-term history of chronic left medial knee 
pain, and 6-month history of left lateral knee pain with associated mechanical symptoms. Clinical exam 
findings are consistent with reported imaging evidence of a lateral parameniscal cyst with superficial dissection 
around the fibular head, and severe medial compartment arthritis with degenerative tearing of the meniscus. 
There is some peroneal nerve compression report with no sensory or motor deficits. Surgical options were 
discussed to include cyst excision and total knee arthroplasty. Current evidence based medical literature would 
not support this request in the setting of severe osteoarthritis and the absence of positive provocative meniscal 
testing. The enrollee does not have a diagnosis, condition, and/or symptoms that meet the Medicare criteria for 
knee meniscectomy, and this would not be considered the standard of care. Therefore, the request for knee 
meniscectomy is not medically reasonable and necessary for treatment of the enrollee's medical condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of knee arthroscopy meniscectomy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve knee arthroscopy meniscectomy.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ILUMYA.
You asked the Plan to pre-approve ILUMYA. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.
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 ILUMYA.
Benefits for ILUMYA 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the rebase complete mandibular denture (D5711). 
 
You asked the Plan to pre-approve the rebase complete mandibular denture (D5711). You say that you cannot 
eat properly without dentures. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
rebase complete mandibular denture (D5711).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CT Scan of the cervical spine (72126) provided on 
December 3, 2019. 
 
You asked the Plan to pay for the CT Scan. 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. 
 
In this case, the CPT Code Manual definition of code 72126 is computed tomography, cervical spine; with 
contrast material. 
 
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 CT Scan. Our reviewer says that CPT code 72126 does 
not meet criteria for billing or reimbursement consideration. Our reviewer found the procedure report does not 
indicate that contrast material was used. There is a more appropriate code that should be used to bill for 
services provided. 
 
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 CT Scan have not been met. Therefore, we decided that the Plan does not 
have to pay for a CT Scan of the cervical spine (72126) provided on December 3, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says services that can only be provided as an inpatient in a skilled nursing facility are not required.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. She does not have complex wound care or other ongoing SNF level skilled nursing need. She does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. She does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting.
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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary and mandibular partial dentures. 
 
You asked the Plan to pre-approve maxillary and mandibular partial dentures. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says you have exhausted your benefit 
limit. 
 
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. 
 
Dentures are only covered once every five years. Review of the file shows that you received dentures on 
December 20, 2019. Five years had not passed since your previous dentures. Though the Plan offers a dental 
benefit in excess of Medicare coverage, the requested items or services are not among those covered under this 
benefit. Therefore, we decided that the Plan does not have to pre-approve maxillary and mandibular partial 
dentures.
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 these services are medically necessary. The Plan denied your request. The Plan says that the member's current needs are being met in the acute setting.
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. The short-term acute care hospital can provide for all the patient's present inpatient care needs and the patient is receiving an appropriate level of care in the present setting. Continued care in the short-term acute care hospital is appropriate until the patient is stable to transfer to a lower level of care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for diagnostic services (82248, 80053, 84439, 84443, 85025, A9585, 70553, A9952, 71046, 78815, 94760) provided from February 5, 2020 to February 13, 2020.
You asked the Plan to waive the cost sharing for diagnostic services. You say that you have already paid your deductible and copay. The Plan denied your request. The Plan says these services processed correctly.
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 20% coinsurance for diagnostic tests and supplies including x-rays, medical supplies, lab services, non-radiological diagnostic services, and diagnostic radiology services until you meet the $2,000 out-of-pocket-maximum.
You have been asked to pay a $679.47 coinsurance for diagnostic services ($3,498.18 allowed amount x 20% = $699.67, which exceeded the out-of-pocket maximum). 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 cost sharing for diagnostic services (82248, 80053, 84439, 84443, 85025, A9585, 70553, A9952, 71046, 78815, 94760) provided from February 5, 2020 to February 13, 2020.