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

We decided that the Plan has to pre-approve the combination of drugs
Carboplatin/Pemetrexed/Pembrolizumab.
You asked the Plan to pre-approve the requested combination of drugs. You say that this combination of
medication is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says that
the criteria for coverage have not been met in this case.
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 combination of drugs.
Our reviewer says that the combination of chemotherapy drugs Carboplatin/Pemetrexed/Pembrolizumab is
medically necessary for the enrollee's condition. Our physician reviewer found the enrollee is a 69-year-old
male diagnosed with non-small cell lung cancer. In this case, the requested drug combination is FDA-approved
for the enrollee's condition. Specifically, this is first line therapy for this patient who now has metastatic disease
after resection of a non-small cell adenocarcinoma of the lung in 2018. He has no driver mutations and, due to
extensive disease, combination therapy would be preferred 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 the requested combination of drugs have been met. Therefore, we decided that
the Plan has to pre-approve the combination of drugs Carboplatin/Pemetrexed/Pembrolizumab.
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 pre-approve angioplasty with stent placement.
You asked the Plan to pre-approve angioplasty. You say that the enrollee needs angioplasty due to chronic nonocclusive
deep vein thrombosis (DVT) of the left popliteal vein. The Plan denied your request. The Plan says
the denial of authorization for this service is correct, because this is not medically necessary.
The Plan follows Medicare rules. Medicare rules state that angioplasty may be covered under 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 angioplasty. Our reviewer says that the
enrollee does not meet the Medicare criteria for angioplasty. Our physician reviewer found the enrollee has
nonocclusive deep vein thrombosis (DVT) of the left popliteal vein. She is presently on Eliquis. Therefore, the
enrollee does not meet any of the coverage indications for this angioplasty.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of angioplasty have not been met. Therefore, we decided that the Plan does not
have to pre-approve angioplasty with stent placement.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2615, E1028) for the enrollee.
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the accessories. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested items exceed the enrollee's medical needs. The E2615 positioning wheelchair back cushion is already included in the tilt and recline and therefore not medically necessary. The E1028 swing away bracket hardware for the joystick exceeds the enrollee's medical needs as the approved wheelchair arms are able to be flipped back to perform a similar function. 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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2615, E1028) for the enrollee
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the outpatient surgery provided on September 2, 2021.

You asked the Plan to waive the copay for the outpatient surgery. You say that you should not be billed because the surgery was cancelled. The Plan denied your request. The Plan says that the copay was assessed correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $395 copay for outpatient surgery. 

You have been asked to pay a $395 copay for the outpatient surgery. The outpatient surgery falls within the outpatient surgery 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 outpatient surgery provided on September 2, 2021.
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 requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does
not meet criteria.
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 the enrollee appears to be improving and should only require short-term additional
acute care services that can safely be received 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. Transfer to a lower level
of care may be considered soon when treatment has completed.
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health (HH) skilled nursing (SN) services (CPT code G0299 x 3), for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says there have been no recent changes to the enrollee's treatment plan or their medications. The Plan states the enrollee's records show that their medical conditions, medication management, diet, and household safety have been reviewed with the enrollee and their caregiver(s). The Plan states the enrollee's records do not support the need for a skilled nurse to make more visits.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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. physician reviewer found the health plan's denial should be upheld. The enrollee does not have documented skilled nursing needs. As such, the requested, ongoing, HH SN services are not medically necessary or reasonable. 

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 home health (HH) skilled nursing (SN) services (CPT code G0299 x 3), for the enrollee.
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 requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does
not meet criteria.
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 the enrollee appears to be more stable but has a poor prognosis and should only
require short-term additional acute care services that can safely be received 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. Transfer to a lower level of care may be considered soon when treatment has completed.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
You asked the Plan to pre-approve a RFA of the SI joint. You say that this procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is considered experimental/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 a RFA of the SI joint. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this RFA procedure is considered an experimental/investigational procedure due to the wide variation in efficacy reported in the literature. Therefore, the request is considered 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 a RFA of the SI joint have not been met. Therefore, we decided that the Plan does not have to pre-approve a radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for a colonoscopy provided on July 13, 2021.
You asked the Plan to reduce the coinsurance for the colonoscopy. You say that you thought the procedure was
covered and you would only be responsible for $200. The Plan denied your request. The Plan says the correct
coinsurance 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 50%
coinsurance for each diagnostic colonoscopy provided at an out-of-network (OON) outpatient hospital.
You have been asked to pay $783.36, which is 50% of the allowed amount for the colonoscopy $1566.73
allowed amount x 50% coinsurance = $783.36). The colonoscopy falls within the Outpatient Diagnostic Tests
and Therapeutic Services and Supplies 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 reduce the coinsurance
for a colonoscopy provided on July 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Foundation Pain Index testing provided on July 5, 2021.
You asked the Plan to pay for Foundation Pain Index testing. You say that you are appealing with supporting
records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because
the value and effectiveness of this testing has not been demonstrated in peer-reviewed literature.
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 pay for Foundation Pain Index testing. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found this type of testing has not yet been shown in high-quality peer-reviewed literature to
be effective and safe in the long-term, leading to overall improved outcomes to justify its use at this time.
Standard trials of non-opioid medications are recommended to be completed regardless of the results of this
testing.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Foundation Pain Index testing have not been met. Therefore, we decided that
the Plan does not have to pay for Foundation Pain Index testing provided on July 5, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the continuous intraoperative neurophysiology monitoring (G0453), needle electromyography studies (51785), needle electromyography (95870) and somatosensory testing (95938) provided on March 18, 2021.
You asked the Plan to pay for the continuous intraoperative neurophysiology monitoring (G0453), needle electromyography studies (51785), needle electromyography (95870) and somatosensory testing (95938). You say that the rendering provider was requested to participate in the surgery as a blind provider and the provider selection was beyond the control of the patient. You say that the claim should be reconsidered. The Plan denied your request. The Plan says that the time limit for filing has expired.
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. Specifically, the claim was filed timely, and the Plan has not forwarded any evidence as to why these services are not payable. Therefore, we decided that the Plan has to pay for the continuous intraoperative neurophysiology monitoring (G0453), needle electromyography studies (51785), needle electromyography (95870) and somatosensory testing (95938) provided on March 18, 2021.
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 LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan
denied your request. The Plan says the stay is not medically necessary.
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 there is no documentation provided indicating medical necessity for LTACH
services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not
require services at the LTACH that are not available at the acute care hospital where they are currently
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at
the health care setting being offered by the health plan. The requested LTACH services are not medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished
safely and effectively only on an inpatient basis.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the Skilled Nursing Facility (SNF) services provided on December 1, 2020, to December 9, 2020, and billed with Patient Driven Payment Model score KDKE1 x 8 days.

You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says the documentation submitted does not support the PDPM score billed.

The Plan must follow Medicare rules. Medicare rules say that all SNF Part A inpatient services are paid under a prospective payment system (PPS). 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services billed with PDPM score KDKE1 x 8 days have not been met. Specifically, the documentation submitted is incomplete. Section GG Self-Care and Mobility items and Section I0020B, primary medical ICD Code, have not been coded. We are unable to validate the PDPM code billed without this information. Therefore, we decided that the Plan does not have to pay for the Skilled Nursing Facility (SNF) services provided on December 1, 2020, to December 9, 2020, and billed with Patient Driven Payment Model score KDKE1 x 8 days.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from
August 14, 2021, through August 15, 2021.
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says the inpatient admission was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights.
In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 14, 2021, through
August 15, 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 the admission to an LTACH is medically
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically
necessary.
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 continues to receive acute care services, and these have not been
denied. The medical record does not indicate that the enrollee requires services that she is not currently
receiving but that would be available at the LTACH 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 LTACH services.