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

 We decided that the Plan does not have to pre-approve Cyclophosphamide, Doxorubicin HCL, Brentuximab, Vincristine Sulfate, Rituximab and Granisetron Hydrochloride for the enrollee.  You asked the Plan to pre-approve these drugs. You say that these drugs are medically necessary for the patient's treatment for B cell Lymphoma. The Plan denied your request. The Plan says that they determined 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 these drugs. Our reviewer says that these drugs are not medically reasonable and necessary for the enrollee. The requested use of Cyclophosphamide, Doxorubicin HCL, Brentuximab, Vincristine Sulfate, Rituximab and Granisetron Hydrochloride is not FDA-approved for the enrollee's diagnosis. The use of these drugs is not supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services approved medical journal. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these drugs.  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 drugs have not been met. Therefore, we decided that the Plan does not have to pre-approve Cyclophosphamide, Doxorubicin HCL, Brentuximab, Vincristine Sulfate, Rituximab and Granisetron Hydrochloride for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.      We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you do not require an intensive inpatient rehabilitation therapy program. There is concern that you will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF due to your reported deficits with strength and endurance. Care at the skilled nursing facility level appears to be appropriate 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for emergency room services (99285) provided May 16, 2020.  You asked the Plan to pay for the emergency room services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was not filed timely.    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 emergency room services was not filed until July 23, 2021. 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 emergency room services (99285) provided May 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).  You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the documentation provided does not include substantial evidence that suggests that you are suffering from moderate to severe lower back pain that limits your ability to maintain your activities for daily living independently.  The Plan must follow Medicare rules. Medicare rules say that RFA can be covered if the LCD criteria is 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 requested services are not considered medically reasonable and necessary in this case. The clinical documentation provided does not include substantial evidence that suggest that you are suffering from moderate to severe lower back pain and or limits your ability to maintain your activities for daily living independently. The clinical documentation provided reports that you have tried other treatment measures to manage your pain, but the documentation does not list the treatment measures you have tried and or failed, the duration of the treatment measures used and the evaluation of these other treatment's methods. The documentation provided does not indicate that there are any other co-morbidities and/or possible causes for the your pain. Our physician reviewer found that your condition does not meet Medicare criteria for these services.  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 radiofrequency ablation (RFA).
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on July 3, 2021.  You asked the Plan to waive the copayment for the ER visit. You say that the ER staff never physically examined you to determine where your bleeding was coming from and you were given a medication you did not need. You do not think you should have to pay a copayment for this. The Plan denied your request. The Plan says you were charged this copayment 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 $120 copayment for emergency room visits.       You have been asked to pay a $120 copayment for the ER visit. This copayment applies regardless of your satisfaction with these services. 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 the emergency room (ER) visit you had on July 3, 2021.   Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Vita Risk lab test.  You asked the Plan to pre-approve a Vita Risk lab test. You say that the requested test is needed to determine whether you are part of the percentage of people who can take vitamins to attack the retina and treat your condition. The Plan denied your request. The Plan says the medical necessity criteria has not been 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 a Vita Risk lab test. Our reviewer says that a Vita Risk lab test is not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has exudative macular degeneration. The requested test is to determine risk for developing exudative macular degeneration.   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 Vita Risk lab test have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vita Risk lab test.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.      We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does require physical therapy and occupational therapy services but based on the medical records provided the enrollee does not require an intensive inpatient rehabilitation therapy program. Care at the skilled nursing facility level appears to be appropriate 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayment for the epidural steroid injection procedure you had at an outpatient hospital facility on January 15, 2021.  You asked the Plan to reduce the copayment for the epidural steroid injection procedure. You say that you had this procedure at an ambulatory surgical center, not a hospital, so your copayment should only be $300. The Plan denied your request. The Plan says you were charged this copayment 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 $350 copayment for outpatient surgery at an outpatient hospital facility.   You have been asked to pay a $350 copayment for the epidural steroid injection procedure.   We have confirmed that the facility where you received these services is an outpatient hospital facility, not an ambulatory surgical center.  The Plan's online directory shows this facility is considered a hospital.  In addition, this facility is registered with the Centers for Medicare and Medicaid Services as a hospital, not as an ambulatory surgery center.  That is why the epidural steroid injection procedure falls within the outpatient surgery at an outpatient hospital facility 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 copayment for the epidural steroid injection procedure you had at an outpatient hospital facility on January 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Corus CAD testing provided on September 15, 2020.  You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically necessary.  The Plan follows Medicare rules. Medicare rules say that the Corus CAD test is 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 the testing. Our reviewer says that the requested testing is not medically reasonable and necessary. Our physician reviewer found that the Corus CAD test is a quantitative gene expression test intended to rule out coronary artery disease (CAD) in stable non-diabetic patients. Data regarding its clinical usefulness in elderly (Medicare-aged) patients, particularly males, is significantly lacking in all scientific articles. The Corus CAD test was not medically reasonable or necessary according to the coverage criteria established in the above LCD.  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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the Corus CAD testing provided on September 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to provide coverage for additional routine transportation trips (A0120).  You asked the Plan to provide coverage for additional routine transportation trips. You say that you are requesting additional transportation because you need to go to the doctor to get your medication pump. The Plan denied your request. The Plan says you have exhausted the maximum benefit of 60 one-way trips per year.  Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 trips per year.    We looked at your request, the records in the case file, and the rules. The records show that you have used 60 one-way transportation trips this year. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips (A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient office visit (99202) provided July 20, 2021.  You asked the Plan to pay for the office visit. You say that you had called the Plan and was given names of in-network providers, but you were not informed that you were financially responsible for a new patient office visit. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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 service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99202) provided July 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on July 9, 2021.  You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.  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 the x-ray services is a column II code to column I code 71045 for 32555. 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 the x-ray services coded 71045 provided on July 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for wound care services provided on July 12, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the OON wound care services. You say that these services were medically necessary and were provided in good faith. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.    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 had network providers available who could have provided 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 wound care services provided on July 12, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve transforaminal epidural injections.  You asked the Plan to pre-approve transforaminal epidural injections. You say that the enrollee received greater than 50% pain relief from the previous injection. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because repeat injection is not supported for the enrollee.  The Plan follows Medicare rules. Medicare rules state that it is not considered medically reasonable and necessary to perform transforaminal epidural steroid injections (TSEFIs) at more than 2 nerve root levels during the same session.  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 transforaminal epidural injections. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested transforaminal epidural injections. Our physician reviewer found according to the coverage criteria, it is not considered medically reasonable and necessary to perform TFESIs at more than two (2) nerve root levels during the same session.  The review has determined that the enrollee does not meet the coverage criteria for transforaminal epidural steroid injections at more than one level.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of transforaminal epidural injections have not been met. Therefore, we decided that the Plan does not have to pre-approve transforaminal epidural injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our physician reviewer found you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device for the enrollee.  You asked the Plan to pre-approve these services. You say that the patient is in need of pain management. The Plan denied your request. The Plan says that this is contraindicated for the enrollee.  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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The vertiflex device is experimental. More research is needed to show safety and efficacy of the device. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services.  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 the Vertiflex Superion Interspinous device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (22845-59) provided on October 7, 2020.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service is not supported.  The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.    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 the services Our reviewer says that the use of modifier -59 is not supported in this case. Our physician reviewer found that in order to report CPT 22845 and CPT 22853 as separate services, the documentation must show a completely separate plate that spans the interspace, to provide independent stabilization, which is not considered integral to the intervertebral device. The operative report does not include documentation to support criteria for modifier -59.  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 pay for the services (22845-59) provided on October 7, 2020.