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

We decided that the Plan does not have to pre-approve Cyramza (J9308).

You asked the Plan to pre-approve Cyramza. You say that this is standard treatment.The Plan denied your request. The Plan says this use of Cyramza is not supported.

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 Cyramza. Our reviewer says that the requested use of Cyramza is not supported. Our physician reviewer found Cyramza is only FDA approved as first-line therapy in combination with Osimertinib. This patient has progressive disease. The requested use is also not supported by one of the major drug compendia or by clinical research.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Cyramza have not been met.Therefore, we decided that the Plan does not have to pre-approve Cyramza (J9308).
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.

You asked the Plan to pre-approve IRF care. You say that without acute rehab the enrollee is in danger of not regaining maximum function. The Plan denied your request. The Plan says the enrollee does not need an intensive team for care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve an epidural steroid injection.

You asked the Plan to pre-approve injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT) (62321). You say that the enrollee needs the injection for pain relief. The Plan denied your request. The Plan says that the requested service is not supported without taking part in an exercise program.

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 injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT) (62321). Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the patient had a trial of conservative care. The request is 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 injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT) (62321) have been met. Therefore, we decided that the Plan has to pre-approve an epidural steroid injection.

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (J9271).

You asked the Plan to pre-approve Keytruda (J9271). You say that you want the enrollee treated with this drug.The Plan denied your request. The Plan says medical studies have not proven that the drug is helpful when you have already tried a similar drug and did not have a positive response.

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 (J9271). Our reviewer says that the drug is not medically necessary. Our physician reviewer found the patient has not failed checkpoint inhibiter(opdivo) thus deny Keytruda as a single agent as not compendia based.

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 (J9271) have not been met.Therefore, we decided that the Plan does not have to pre-approve Keytruda (J9271).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for anesthesia services provided on October 6, 2020.

You asked the Plan to waive the coinsurance for anesthesia services. You say that you disagree with the charges because you did not know that the provider was out-of-network. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

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 20% coinsurance for out-of-network physician/practitioner services provided at an ambulatory surgical center or outpatient hospital facility.

You received anesthesia services at an out-of-network provider, on October 6, 2020. Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. The total allowed amount is $345.96 and 20% of that is $69.19.

You have been asked to pay the total coinsurance amount of $69.19 for out-of-network anesthesia services. Out-of-network anesthesia services fall within the physician/practitioner services, including doctor's office 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 coinsurance for anesthesia services provided on October 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic radiographic image (D0330), the intraoral - complete series of radiographic images (D0210) and the unspecified preventive procedure (D1999).

You asked the Plan to pay for the dental services (D1999, D0330, D0210). You say that you do not remember receiving panoramic imaging in the past three years. The Plan denied your request. The Plan says the requested services are either excluded or in excess of the supplemental 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. The Plan does not cover unspecified preventive procedure (D1999). The Plan has provided evidence that you received full mouth or panoramic radiographic images within the last three years. Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D0330), the intraoral - complete series of radiographic images (D0210) and the unspecified preventive procedure (D1999).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.

You asked the Plan to pre-approve inpatient psychiatric hospital services from April 9, 2021, and beyond. You
say that inpatient psychiatric hospital services are medically necessary. The Plan denied your request. The Plan
says medical necessity is not met for days April 9, 2021, and forward.

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 inpatient psychiatric hospital services
from April 9, 2021, and beyond. Our reviewer says that the service is not medically necessary. Our physician
reviewer found based upon review the records provided, this patient does not meet the criteria for treatment in
an acute inpatient mental health treatment beyond the date in question of April 9, 2021, forward and could have
been treated in a lesser restrictive setting as the enrollee was not showing any suicidal or homicidal ideation,
auditory or visual hallucinations and was not showing any aggressive behaviors being cooperative and
compliant.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient psychiatric hospital services from April 9, 2021, and beyond have not
been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital
services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2311, E2313).
You asked the Plan to pre-approve an expandable controller. You say that these items are necessary for the wheelchair to function properly. The Plan denied your request. The Plan says the power options can be controlled through their own switches
The Plan follows Medicare rules. Medicare rules say that an expandable controller is covered when it is necessary for the functions listed in the LCD.
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 expandable controller. Our reviewer says that the requested expandable controller is not medically necessary. Our physician reviewer found the submitted medical records indicate that the enrollee has adequate upper extremity strength and function to control the power options with their own switches. 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 expandable controller have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377, E2311, E2313).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the teeth extractions received from an out-of-network (OON) provider.
You asked the Plan to pay for the teeth extractions. You say that this provider participates in the Plan's network. The Plan denied your request. The Plan says items and services received from an out-of-network provider are not covered.
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 Plan does not cover items and services received out-of-network. The Plan has confirmed that the provider in this case was not in-network on the date of service. Therefore, we decided that the Plan does not have to pay for the teeth extractions received from an out-of-network (OON) provider.
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.
You asked the Plan to pre-approve IRF care. You say that an inpatient rehabilitation stay is medically necessary and the best treatment option for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet requirements for multiple therapies.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve 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 physical therapy services provided on January 6, 2021.

You asked the Plan to pay for the physical therapy services. You say that you were unaware a referral/authorization was needed. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 physical therapy services. 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 physical therapy services provided on
January 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 7, 2020.
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 services were billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on January 4, 2021.

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 billed incorrectly.

The Plan must follow Medicare rules. The rules say that a Revenue Code is required for billing on the CMS-1450 claim form. 

We looked at the file and Medicare rules. The file shows that the claim was not billed with a valid revenue code. 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 services rendered on January 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression socks identified with code 99998.
You asked the Plan to pre-approve compression socks. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not a covered benefit.
The Plan must follow Medicare rules. The rules say that compression stockings described by code 99998 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression socks identified with code 99998.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve a cervical epidural steroid injection for the enrollee.

You asked the Plan to pre-approve the injection. You say that this is medically necessary.The Plan denied your request. The Plan says that there are no findings on exam or a CT consistent of nerve root compression.

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 the injection. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the request is for a cervical epidural steroid injection, not a caudal injection. The imaging shows C5-C6 disc disease. The enrollee meets the criteria for this request, and it is considered 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 the injection have been met.Therefore, we decided that the Plan has to pre-approve a cervical epidural steroid injection for the enrollee.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95885), nerve conduction studies
(95908), and a diagnostic procedure (95999) provided on February 10, 2020.
You asked the Plan to pay for needle electromyography, nerve conduction studies, and. You say that these
codes are documented. The Plan denied your request. The Plan says these codes are 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 95885 is needle electromyography, each extremity, with
related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study;
limited (List separately in addition to code for primary procedure). The definition of 95908 is nerve conduction
studies; 3-4 studies. The definition of 95999 is unlisted neurological or neuromuscular diagnostic procedure.
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 needle electromyography, nerve conduction
studies, and. Our reviewer says that the billing of these codes is not supported in the records. Our physician
reviewer found the procedure report does not include documentation that stimulating and recording electrodes
were placed over a nerve, therefore, CPT 95908 cannot be verified as performed. CPT 95908 is an
inappropriate code to report for the stimulation of pedicle screws as documented. The submitted documentation
does not include enough detail to confirm an unlisted neurological or neuromuscular procedure represented by
CPT 95999 has been performed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of needle electromyography, nerve conduction studies, and have not been met.
Therefore, we decided that the Plan does not have to pay for needle electromyography (95885), nerve
conduction studies (95908), and a diagnostic procedure (95999) provided on February 10, 2020.