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

We decided that the Plan does not have to pre-approve a nuclear stress test 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 services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a nuclear stress test is covered when specific criteria are met. 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 increased coronary risk, chest discomfort that sounds nonanginal (nonexertional and lasts seconds), a normal cardiovascular physical exam and an interpretable electrocardiogram. In this circumstance, additional evaluation for coronary ischemia is not recommended in patients with nonanginal chest pain or inpatients who are asymptomatic with high coronary risk. Moreover, if further evaluation for coronary ischemia were thought to be medically necessary then standard treadmill electrocardiography should be sufficient given the patients interpretable electrocardiogram and no documented inability to exercise on a treadmill. The nuclear stress testing 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 a nuclear stress test for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit services provided on October 8, 2019 by an out of network provider.
You asked the Plan to pay for the hospital outpatient clinic visit services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 the hospital outpatient clinic visit services provided on October 8, 2019 by an out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve paravertebral facet joint injection services.
You asked the Plan to pre-approve the paravertebral facet joint injection services. You say that the records provided support the need for the requested injection services. The Plan denied your request. The Plan says the clinical information does not show that the criteria for coverage have been met and the requested injections are not indicated at this time. The Plan follows Medicare rules. Medicare rules say that paravertebral facet joint injections are covered for certain indications. 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 paravertebral facet join injection services. Our reviewer says that the criteria for coverage have not been met and the requested injections are not indicated at this time. Our physician reviewer found the enrollee has a history of neck/cervical spine pain. An MRI of the cervical spine revealed multilevel spondylosis, moderate C4-5 thecal sac stenosis. On April 26, 2018 the enrollee underwent a facet steroid injections of C3-C4, C4-C5, C7-T1, and T1-T2. On May 24, 2018 they underwent radiofrequency ablation (RFA) of bilateral C3, C4, C5 with 80% relief. On September 13, 2018 they underwent bilateral RFA C7-T1, and T2 and experienced some relief x2 months. On October 23, 2019 the physician recommended repeat bilateral RFAs at C7-T1,and T2. There have been no recent MBBs to document a clinical response. The repeat bilateral C7- T1, and T2 RFAs remain denied given the time that has lapsed since prior treatment and considering the previous response to RFAs did not meet Medicare criteria for approval. 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 paravertebral facet join injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve paravertebral facet join injection services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of interlaminar/interspinous process stabilization/distraction device (22869 and 22870).
You asked the Plan to pre-approve the insertion of interlaminar/interspinous process stabilization/distraction device. You say that this is medically necessary. The Plan denied your request. The Plan says this service is experimental and unproven.
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 insertion of interlaminar/interspinous process stabilization/distraction device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the available medical literature does not adequately demonstrate that interlaminar/interspinous process stabilization/distraction devices are safe and effective. More research is needed to demonstrate the safety and efficacy of such devices. A relatively high rate of complications with the device has been reported. The documentation does not support that the requested interlaminar/interspinous process stabilization/distraction device is medically reasonable and necessary for the enrollee in this case. 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 insertion of interlaminar/interspinous process stabilization/distraction device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of interlaminar/interspinous process stabilization/distraction device (22869 and 22870).
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. The Plan denied your request. The Plan says this drug is not medically necessary.
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 reasonable and necessary. Our physician reviewer found Pembrolizumab in hepatobiliary cancers such as cholangiocarcinoma is only FDA approved for use in tumors that are microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR). Off-label use is not supported by major drug compendia. The use of pembrolizumab (Keytruda) 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 the chiropractic services provided on August 13, 2019 to October 16, 2019 by an out of network provider.
You asked the Plan to pay for the chiropractic services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.
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 the chiropractic services provided on August 13, 2019 to October 16, 2019 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical nutrition therapy and consultation services
You asked the Plan to pre-approve medical nutrition therapy and consultation services. You say that you have not eaten since the denial of the requested service. You say that you medically need nutritional therapy. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage of nutritional therapy services.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does not have to pre-approve medical nutrition therapy and consultation services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home health aide, five times a week for the enrollee.
You asked the Plan to pre-approve the aide. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit, without the presence of a skilled need.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 aide. Our reviewer says that the requested aide is not medically reasonable or necessary. Our physician reviewer found based on available records, the enrollee does not meet criteria for coverage of the requested home health aide 5 days per week. The enrollee does not have any documented skilled nursing needs or skilled therapy needs. The enrollee's current needs are custodial in nature. The home health aide services are not reasonable and necessary to the treatment of the enrollee's illness or injury by the skilled professional staff. This is not a covered benefit, without the presence of a skilled need. 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 aide have not been met. Therefore, we decided that the Plan does not have to pre-approve a home health aide, five times a week for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 16, 2019 by an out of network provider.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.
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 the laboratory services provided on August 16, 2019 by the out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on August 22, 2019 by an out of network provider.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 the drug testing provided on August 22, 2019 by the out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 27, 2019 by an out of network provider.
You asked the Plan to pay for the pain management services (64493, 64494, 64495 and 64450). You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the member does not have out-of-network benefits.
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 the medical services provided on August 27, 2019 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chemotherapy administration services coded 96413, the injection services coded 96375, and the intravenous infusion services coded 96367 provided on July 24, 2019.
You asked the Plan to pay for the chemotherapy administration services, the injection services, and the intravenous infusion services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 96413, 96375, and 96367 is not supported in the medical record. Specifically, the submitted documentation did not contain sufficient detail to support the billed charges. The documentation did not indicate the time over which the infusion was administered to the enrollee. The submitted Infusion Nurse Note did notate the administration date along with a time. However, the notes did not specify how much time was spent infusing the enrollee nor did it state a start and stop time of the infusion. Therefore, code 96413 cannot be verified. Codes 96375 and 96367 remain unsupported due to the required primary service code being denied. Based on this information, we decided that Medicare rules for coverage of the chemotherapy administration services, the injection services, and the intravenous infusion services have not been met. Therefore, we decided that the Plan does not have to pay for the chemotherapy administration services coded 96413, the injection services coded 96375, and the intravenous infusion services coded 96367 provided on July 24, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 additional outpatient therapy visits.
You asked the Plan to pre-approve 12 additional outpatient therapy visits. You say that these services are medically necessary. The Plan denied your request. The Plan says while 8 of the 12 visits were approved, the Medicare coverage criteria are not met for the remaining 4 visits.
The Plan must follow Medicare rules. The rules say that Medicare pays outpatient therapy when 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 this service. Our reviewer says additional outpatient therapy criteria are not met. Our physician reviewer found based on the medical records provided therapy needs at this point can be met with a home exercise program and instruction. Criteria for the 4 additional outpatient therapy visits requested are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional outpatient therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 4 additional outpatient therapy visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for Train of Four Testing (95999) provided on December 12, 2018
You asked the Plan to pay for the Train of Four Testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says separate payment for Train of Four Testing is not a covered benefit.
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 record. Specifically, Train of Four testing is included in the approved primary neuromonitoring service. Based on this information, we decided that Medicare rules for coverage of the Train of Four Testing have not been met. Therefore, we decided that the Plan does not have to pay for Train of Four Testing (95999) provided on December 12, 2018
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a craniectomy (61312) provided on August 31, 2019.
You asked the Plan to pay for the craniectomy. You say that the services rendered were medically necessary. The Plan denied your request. The Plan says payment for this service is included in the facility claim.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the craniectomy have not been met. Specifically, the member was admitted as inpatient on this date of service indicating that the payment for this service is included in the facility claim. Therefore, we decided that the Plan does not have to pay for a craniectomy (61312) provided on August 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (00810) provided on April 5, 2018.
You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration as the services rendered were medically necessary. The Plan denied your request. The Plan says the claim was received past the timely filing guideline of 1 year from the date of service.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for the anesthesia services was not filed until July 17, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for anesthesia services (00810) provided on April 5, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Humira pen injection.
You asked the Plan to pre-approve a Humira pen injection. The Plan denied your request. The Plan says this is not covered under the enrollee's medical plan.
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 a Humira pen injection.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care beyond January 23, 2020.
You asked the Plan to pre-approve continued SNF care. The Plan denied your request. The Plan says this is not medically necessary.
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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for 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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care beyond January 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services and hip strapping provided from May 28, 2019 to May 30, 2019.
You asked the Plan to pay for chiropractic services. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services are not covered by Medicare or the Plan when performed by a chiropractor
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue were not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for therapy services and hip strapping provided from May 28, 2019 to May 30, 2019.