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

We decided that the Plan does not have to pay for the radiofrequency ablation (RFA) of the lateral sacral nerve
branches provided on June 2, 2021.
You asked the Plan to pay for the sacral nerve RFA procedure. You say that it is felt this should be covered as
it is beneficial to the patient. The Plan denied your request. The Plan says this is not a proven treatment and is
not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. ked 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 the sacral nerve RFA procedure. Our
reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found the enrollee has chronic low back pain and has tried anti-inflammatories, muscle
relaxants, and a home exercise program. She has had diagnostic sacroiliac joint injections, and then this RFA
procedure.
RFA of the lateral sacral branches is considered experimental/investigational because of the wide variation in
efficacy described in the literature. Therefore, the procedure was medically unreasonable and unnecessary.
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 sacral nerve RFA procedure have not been met. Therefore, we decided that
the Plan does not have to pay for the radiofrequency ablation (RFA) of the lateral sacral nerve branches
provided on June 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Darzalex and Dexamethasone. You asked the Plan to pre-approve Darzalex and Dexamethasone. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. In this case, you asked the Plan to pre-approve Darzalex and Dexamethasone as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve Darzalex and Dexamethasone.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for cardioversion services (procedure code 92960) provided to the enrollee on March 7, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says an appropriate modifier was not billed in this case.
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, we have confirmed that code 92960 is a column II code to column I code 99291. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for cardioversion services (procedure code 92960) provided to the enrollee on March 7, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that you need SNF care. The Plan denied your 
request. The Plan says the rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 you are an 87-year-old man with a 
history of chronic obstructive pulmonary disease. Based on the documentation provided, you do not have 
documented skilled nursing needs. Furthermore, you do not have documented skilled therapy needs. Daily 
skilled services are not required to establish a maintenance program or to prevent deterioration of your 
condition. Your care needs are custodial and, as a practical matter, can be provided at a lower level of 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the continuation of skilled nursing facility (SNF) care
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on January 12, 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 procedure code 97110 is 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 97110 is therapeutic procedure, 1 or more areas, each 15
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.
We find that CPT code 97110 is not supported in the medical record. Specifically, the records show that the
services were performed in the home health setting and there is a more appropriate code for these services.
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 physical therapy services rendered on January
12, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Udenyca 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 the requirements were not met.
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 and necessary. Our physician reviewer found the use of pegfilgastrim
such as Udencya is generally recommended to reduce the risk of neutropenic fever when the anticipated risk of
neutropenic fever for a chemotherapy regimen is approximately 20% or higher. However, to minimize possible
emergency care needs during the pandemic, it may be reasonable to provide prophylactic white blood cell
growth factors to patients at a lower anticipated neutropenic fever risk, such as 10%. Given your age, regimen,
and prechemotherapy absolute neutrophil count the use of Udencya is reasonable and medically necessary and
likely to be safe and effective.
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
Udenyca 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Ophthalmology services (99213) provided
July 6, 2021.
You asked the Plan to waive the copayment for the Ophthalmology services. You say that the copayment
should be waived. The Plan denied your request. The Plan says the correct copayment was applied. 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 $35
copayment for specialist visits.
You have been asked to pay a $35 copayment for the Ophthalmology services. The Ophthalmology services
fall within the specialist 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 copayment for
Ophthalmology services (99213) provided July 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the third surgical placement of implant body: endosteal implant (D6010) provided May 24, 2021.
You asked the Plan to pay for the endosteal implant. You say that the implants were approved and should be covered. The Plan denied your request. The Plan says the claims from this date of service have been reprocessed and two endosteal implants have been covered, however the third implant is not covered because it exceeds the Plan's frequency 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. The Plan covers two endosteal implants per year.
We looked at file and Medicare rules. The Plan provided documentation showing that two endosteal implants were covered on May 24, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the endosteal implant has been exceeded. Therefore, we decided that the Plan does not have to pay for the third surgical placement of implant body: endosteal implant (D6010) provided May 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary for
the enrollee's condition. The Plan denied your request. The Plan says the rules for LTACH care have not been
met.
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. Our
physician reviewer found that the patient is an 80-year-old female who was admitted to the acute care hospital
with acute respiratory failure and coronavirus infection. Recent notes show oxygen weaning was initiated and
workup for anemia and lytic lesions is still ongoing.
The provided records show that the patient is gradually improving but workup for anemia/lesions should be
completed before transfer is considered. The patient should only require short-term additional acute care
services that can safely be administered at the current facility. The patient does not require services at the
LTACH that are not already available at the current facility. In addition, there are no services at the LTACH
that the patient requires that are not already available and covered at the current facility. Therefore, LTACH
services will be considered not medically necessary at this time as transfer would not be clinically
advantageous. Transfer may be considered when the patient is more stable and when treatment is complete.
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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar facet joint injections.
You asked the Plan to pre-approve the requested services. You say that the enrollee had greater than 80% relief from previous injections. The Plan denied your request. The Plan says coverage criteria have not been met.
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under certain medical 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 requested services. Our physician reviewer found that the enrollee has chronic low back pain. He has had epidural steroid injections as well as hemilaminectomies. He had 2 prior diagnostic medial branch blocks, which both produced greater than 80% pain relief. He also received 2 therapeutic injections, which produced greater than 80% pain relief. However, the last therapeutic injection was in Sept 2021. The request is to repeat the injections. The coverage criteria limits utilization to one therapeutic session every 3 months if the pain relief is greater than 50%. Three months have not passed. Therefore, at this time, the request is deemed not medically reasonable or 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar facet joint injections.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vectibix to be used in combination with Fluorouracil,
Leucovorin, and Irinotecan.
You asked the Plan to pre-approve the requested drugs. You say that the enrollee has had it before. The Plan
denied your request. The Plan says the drug regimen is not being prescribed for a medically accepted
indication.
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 the requested drugs. Our physician
reviewer found that the enrollee has metastatic colon cancer. The requested use of the drug regimen is not FDA
approved as the enrollee has a KRAS mutated tumor. The requested use is not supported by one of the major
drug compendia or by clinical research that appears in a CMS-approved medical journal. The use is not listed
as not indicated, not supported, or not recommended in any of the compendia. The documentation does not
support that the requested drug is 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 the requested drugs have not been met. Therefore, we decided that the Plan does
not have to pre-approve Vectibix to be used in combination with Fluorouracil, Leucovorin, and Irinotecan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is ready for LTACH 
admission. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute 
care and is currently unstable for transfer to an LTACH. 
 
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. Our 
physician reviewer found that the enrollee appears to be improving and more stable but requires short-term 
additional acute care services that can safely be completed at the current facility. The enrollee does not require 
services at the LTACH that are not already available at the current facility.  
There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current facility. Therefore, this request for LTACH will be considered not medically necessary as transfer to 
LTACH would not be advantageous clinically over completing treatment at the current facility.  
 
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.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for the skilled nursing facility (SNF) care provided from June 4, 2020, to 
July 24, 2020. 
 
You asked the Plan to pay for the SNF care. You say that the plan forwarded claims to the enrollee's medical 
group. You say that the medical group denied the claims stating the claim needed to go to the Plan directly as 
the claims were beyond bill limits. You also say that the claims were submitted timely. The Plan denied your 
request. The Plan says that the claims were not filed within the allowed timeframe. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. the provider submitted the claims within the 12-month timeframe for timely 
filing. Therefore, we decided that the Plan has to pay for the skilled nursing facility (SNF) care provided from 
June 4, 2020, to July 24, 2020.  
 
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 pre-approve whole exome sequencing of mitochondrial genes.
You asked the Plan to pre-approve the whole exome sequencing test. You say that it is felt that this genetic testing would be helpful in treating the enrollee's condition. The Plan denied your request. The Plan says this is not medically necessary testing and is considered experimental.
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 whole exome sequencing test. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has diagnoses of hypoparathyroidism, hypercalcemia, hypercalciuria, severe osteoporosis, and hypogonadotropic hypogonadism. The records indicate that these diagnoses are being treated and does not indicate how the requested test would alter management. The record provided does not establish the medical necessity and reasonableness of the requested service. The elements of the coverage criteria are not satisfied.
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 whole exome sequencing test have not been met. Therefore, we decided that the Plan does not have to pre-approve whole exome sequencing of mitochondrial genes.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a backup battery for use with a continuous positive
airway pressure (CPAP) device.
You asked the Plan to pre-approve the CPAP device battery. You say that this is necessary to allow use of the
CPAP during power outages. The Plan denied your request. The Plan says this is not an item which is covered
by Medicare.
The Plan must follow Medicare rules. Medicare rules say that power adapters and batteries used as alternative
power sources for equipment capable of power operation are not covered by Medicare and will be denied as not
medically necessary.
Although this may be appropriate for you, neither Medicare nor your Plan provide coverage for this item.
Therefore, we decided that the Plan does not have to pre-approve a backup battery for use with a continuous
positive airway pressure (CPAP) device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for facet joint injections.

You asked the Plan to pay for facet joint injections. The Plan denied your request. The Plan says this is not
medically necessary.

The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered for the indications
established in the applicable 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 pay for facet joint injections. Our reviewer says that
the requested facet injections are not medically reasonable and necessary. Our physician reviewer found that
the enrollee has untreated radiculopathy. She also has non-facet pathology that may be the source of pain.
Furthermore, facet joint procedures are considered medically reasonable and necessary when the enrollee has
had two medically reasonable and necessary diagnostic facet joint procedures with each one providing a
consistent minimum of 80% relief. Currently, this enrollee has not undergone two diagnostic facet joint
procedures.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan
does not have to pay for facet joint injections.