Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intradialytic parenteral nutrition for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the requirement is an inability to obtain nutrition through the intestines.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence that this nutrition is medically reasonable or necessary, based on the medical records.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve intradialytic parenteral nutrition for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a PET scan provided to the enrollee on October 21, 2019.
You asked the Plan to pay this claim. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the claim did not contain a valid diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. Medicare has specific coverage criteria for PET scans. In this case, the claim submitted cannot be paid as billed based on an issue with the diagnosis code and the Medicare coverage criteria. Based on this information, we decided that Medicare rules for coverage of this claim as billed have not been met. Therefore, we decided that the Plan does not have to pay for a PET scan provided to the enrollee on October 21, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the interpretation of the MRA of the head provided on October 8, 2019.
You asked the Plan to pay for the MRA interpretation. You say that this should be paid. The Plan denied your request. The Plan says payment was made for code 70551 which is for an MRI of the head and this is a Column I code in relation to 70544 for the MRA.
The Plan must follow Medicare rules. Medicare rules say that Column II codes are not paid when billed with Column I codes unless there is a clinically appropriate modifier used on the Column II code. In this case, CPT code 70544 is Column II in relation to the paid code 70551. No modifier was appended to indicate why this is eligible for separate payment. The documentation does not provide sufficient information to indicate whether there is a modifier that would be appropriate to allow payment. As such, we find that the rules for coverage of the interpretation of the MRA have not been met. Therefore, we decided that the Plan does not have to pay for the interpretation of the MRA of the head provided on October 8, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee does not need multiple intensive therapies requiring the constant supervision by a doctor and nurse who specialize in rehabilitation to safely participate in therapy. 
 
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. Our physician reviewer found you were medically stable, with no evidence of need for supervision by a PMR physician. There is no need for acute rehab nursing care. You may benefit from further PT and OT, but you do not need an intensive therapy program. IRF admission is not medically necessary based on your current functional status and medical stability. 
 
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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the urgent care services you received on November 15, 2019.
You asked the Plan to waive the copay for the urgent care services. You say that you didn't receive any services. The Plan denied your request. The Plan says the copay was applied based on your plan benefits.
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 $45 copay for each Medicare-covered office visit to other providers for urgently needed services. You have been asked to pay a $45 copay for the services provided. The services fall within the urgently needed services 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 copay for the urgent care services you received on November 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xarelto tablets. 
 
You asked the Plan to pre-approve self-administered drugs. You say that the enrollee is at high risk and has been stable on this medication. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered 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 Xarelto tablets.  
 
Benefits for self-administered drugs 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Avastin for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of hepatocellular carcinoma and suspected renal cell carcinoma. He has not tried and failed the plan's required drug of Zirabev. The records do not show that Zirabev would be less effective or contraindicated; therefore, Avastin is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Avastin for the enrollee.
The Plan references Local Coverage Determination (LCD) L33394 in their determination; however, this LCD does not provide coverage criteria for Avastin and was not used in the MAXIMUS determination.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Alvesco for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.
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 Alvesco for the enrollee.
Benefits for these services 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the Inogen One G5 portable oxygen concentrator purchased on September 23, 2019.
You asked the Plan to reimburse you for the portable oxygen concentrator. You say that you were told you would be reimbursed. The Plan denied your request. The Plan says purchased oxygen equipment is not covered by Medicare or the Plan and there is no authorization, referral, or prescription.
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for coverage. We looked at the file and Medicare rules. Purchased oxygen equipment is statutorily non-covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to reimburse you for the Inogen One G5 portable oxygen concentrator purchased on September 23, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided to the enrollee on August 26, 2019.
You asked the Plan to pay for this claim. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says these services were provided at the request of the plan contract facility treating the enrollee. Payment for these services are included in the global facility claim. Payment to the provider is the responsibility of the facility.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The Plan is correct regarding the billing of this claim. Your services were subcontracted by the facility. The Plan will pay the facility based on the global claim. Payment to you for this equipment or service is the responsibility of the facility, not the health plan. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee on August 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four extractions provided on October 14, 2019 and October 30, 2019.
You asked the Plan to pay for the extractions. You say that you thought your provider contacted your insurance plan to make sure these services would be covered. You also say that you would not have had this work done if you knew you would have to pay for it yourself. The Plan denied your request. The Plan says this 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 pay for the four extractions provided on October 14, 2019 and October 30, 2019.
Your complaint about being misled by the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient psychiatric services rendered to the enrollee from
September 5, 2019 to September 10, 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 services were not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the
services were not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital
on August 30, 2019 with schizoaffective disorder, depressed type and social phobia. She presented with
paranoia, aggression, and agitation. Based on the records, it was not expected that she would improve in a
reasonable period of time for the dates in question, as she was not showing suicidal or homicidal ideation and
denied auditory and visual hallucinations. She was compliant with treatment and was not showing any acute
threats to safety. It does not appear that active treatment was taking place. The services were 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 these services have not been met. Therefore, we decided that the Plan does not
have to pay for the inpatient psychiatric services rendered to the enrollee from September 5, 2019 to September 10,
2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Durvalumab for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says that there are no peer-reviewed journal articles that contain recommendations to use Durvalumab off-label to treat Stage II non-small cell lung cancer.
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 the drug. Our reviewer says that the requested drug is medically reasonable or necessary. Our physician reviewer found despite administration of chemoradiotherapy, the prognosis for unresectable stage III non-small cell lung cancer (NSCLC) remains poor. Durvalumab is recommended as maintenance therapy by the NCCN Guidelines for patients with stage III non-small cell lung cancer who are unresectable and have completed 2 or more cycles of definitive chemoradiation without evidence of progression. Although his enrollee has stage IIA disease it is deemed unresectable and being treated like a stage III NSCLC. Durvulamb is reasonable and medically 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 the drug have been met. Therefore, we decided that the Plan has to pre-approve Durvalumab 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on August 19, 2019 and billed under code 80307.
You asked the Plan to pay for drug testing provided under code 80307. You say this claim should be paid. The Plan denied your request. The Plan says the documentation submitted did not include documentation of the method of testing to support the billed code; therefore, the billed service cannot be verified.
The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of testing. The physicians order and the medical records must specifically show how this testing will be used to treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for screening purposes. Based on the records provided, the required Medicare criteria are not met. Therefore, we decided that the Plan does not have to pay for drug testing provided to the enrollee on August 19, 2019 and billed under code 80307.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a cervical or thoracic transforaminal epidural (64479). 
 
You asked the Plan to pre-approve a cervical or thoracic transforaminal epidural. You say that the service is necessary. The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that low back pain may also be produced by "Myofascial Pain Syndrome" in which case there is not nerve root pathology and epidural injections are not 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 a cervical or thoracic transforaminal epidural. Our reviewer says that the service is medically necessary. Our physician reviewer found the thoracic epidural procedure is not related to another epidural injection, rather the enrollee will be having a radiofrequency ablation (RFA) of the sacroiliac (SI) joint. The requested procedure 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 a cervical or thoracic transforaminal epidural have been met. Therefore, we decided that the Plan has to pre-approve a cervical or thoracic transforaminal epidural (64479).  
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LINX reflex management system for the enrollee. 
 
You asked the Plan to pre-approve this is medically necessary.. You say that this is medically necessary. The Plan denied your request. The Plan says this system is considered experimental and investigational. 
 
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 this is medically necessary.. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's GERD is not advanced or refractory to lifestyle modification. The enrollee's LES is normal, and does not require, does not require surgical augmentation. Symptoms are nonprogressive, and are actually improving with weight reduction. Consideration for LINX in this setting appears to be premature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this is medically necessary. have not been met. Therefore, we decided that the Plan does not have to pre-approve the LINX reflex management system for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve psychotherapy services (90837).
You asked the Plan to pre-approve the psychotherapy services. You say that the services are medically necessary. The Plan denied your request. The Plan says rules for coverage were not 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 the psychotherapy services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the patient is not showing any symptoms of suicidal ideation, homicidal ideation, psychosis, substance abuse, physical aggression or self-injurious behavior. She has had a high level of depression and anxiety since childhood. This patient has been taking Depakote, Latuda, Lexapro, Wellbutrin and Xanax with the same dosage since February 22, 2017. The requested sessions are excessive as symptomatology does not agree with medical necessity. 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 psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve psychotherapy services (90837).