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

We decided that the Plan does not have to pre-approve the intracept procedure (22899 and C9752).
You asked the Plan to pre-approve the intracept procedure. You say that the service is medically necessary. The Plan denied your request. The Plan says the service 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 intracept procedure. Our reviewer says that this service is not medically necessary. Our physician reviewer found the intracept procedure remains experimental and more research is needed to show its safety and efficacy. 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 intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the intracept procedure (22899 and C9752).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on March 2, 2021 by an out-of-network provider.
You asked the Plan to pay for the office visit (99214). You say that you thought your staff had obtained prior authorization and you would like the Plan to reprocess the claim as a one-time courtesy. The Plan denied your request. The Plan says you did not request prior authorization as required.
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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for the service. Therefore, we decided that the Plan does not have to pay for the office visit provided on March 2, 2021 by an out-of-network provider.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says your needs can be met at a different level of care. 
 
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 based on the medical records provided the complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. It is not clear you would be able to fully benefit and/or participate in an IRF level of care. 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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says your needs can be met at a different level of care. 
 
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 based on the medical records provided the complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. It is not clear you would be able to fully benefit and/or participate in an IRF 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1851) suspension sleeve (L2397) wrist hand orthosis (L3916) lumbar-sacral orthosis (L0648) provided March 29, 2021.
You asked the Plan to pay for the orthoses. You say that the documentation clearly shows medical necessity based on the doctor's review of the enrollee. The Plan denied your request. The Plan says documentation indicates services are not necessary for treatment of the enrollee's condition.
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1851) suspension sleeve (L2397) wrist hand orthosis (L3916) lumbar-sacral orthosis (L0648) provided March 29, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits. 
 
You asked the Plan to pre-approve additional physical therapy visits. You say that you are appealing the denial 
of continued physical therapy. The Plan denied your request. The Plan says additional visits are not medically 
necessary. The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 additional physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the patient has had prior therapy and should be 
able to transition to an independent home exercise program. Our reviewer says that the unique skills of a 
professional therapist are not required to safely and effectively provide ongoing treatment. 
 
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 physical therapy visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the otolaryngology visit and binocular microscopy you had on May 25, 2021.
You asked the Plan to waive the copayments for the otolaryngology visit and binocular microscopy. You say that you went to this office to have your ear wax removed but they were unable to dislodge it. You say that nothing was done for you, so you shouldn't have to pay these copayments. The Plan denied your request. The Plan says you were charged these copayments 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 $50 copayment for visits with a specialist and a $25 copayment for diagnostic procedures and tests.
You have been asked to pay a $50 copayment for the otolaryngology visit and a $25 copayment for the binocular microscopy. The otolaryngology visit falls within the visits with a specialist benefit category. The binocular microscopy falls in the diagnostic procedures and tests benefit category. These copayments apply regardless of whether the ear wax removal was successful. 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 copayments for the otolaryngology visit and binocular microscopy you had on May 25, 2021.
Your complaint about whether the medical records accurately reflect the services you received is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services provided on April 21, 2021 by an out-of-network provider.
You asked the Plan to pay for the office visit (99212) and removal of nail plate (11730). You say that you were not aware prior authorization was required. The Plan denied your request. The Plan says you did not request prior authorization as required.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the podiatry services provided on April 21, 2021 by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on November 2, 2020.
You asked the Plan to pay for a CT scan. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says this is not separately payable without a modifier.
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 70450 has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on November 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Yervoy (J9228) and Nivolumab (J9299).
You asked the Plan to pre-approve Yervoy and Nivolumab. You say that the drugs are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the clinical criteria for coverage.
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 Yervoy (J9228) Nivolumab (J9299). Our reviewer says that the service is not medically necessary. Our physician reviewer found these drugs are not FDA approved for the enrollee's diagnosis and its use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Yervoy (J9228) NivolumaB (J9299) have not been met. Therefore, we decided that the Plan does not have to pre-approve Yervoy (J9228) and Nivolumab (J9299).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve daratumumab/hyaluronidase-fihj (J9144), carfilzomib (J9047), famotidine injection (J3490), injection diphenhydramine hcl up to 50 mg (J1200), injection dexamethasone sodium phosphate (J1100).
You asked the Plan to pre-approve daratumumab/hyaluronidase-fihj, carfilzomib, famotidine injection, injection diphenhydramine hcl up to 50 mg, injection dexamethasone sodium phosphate. You say that the drugs are medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet the criteria for coverage of these drugs.
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 daratumumab/hyaluronidase-fihj (J9144), carfilzomib (J9047), famotidine injection (J3490), injection diphenhydramine hcl up to 50 mg (J1200), injection dexamethasone sodium phosphate (J1100). Our reviewer says that the service is not medically necessary. Our physician reviewer found these drugs are FDA approved for the treatment of relapsed or refractory multiple myeloma (in combination with pomalidomide and dexamethasone) in adults who have received at least one prior line of therapy, including lenalidomide and a proteasome inhibitor. This patient has had two prior lines of therapy including lenalidomide and bortezomib. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of daratumumab/hyaluronidase-fihj (J9144), carfilzomib (J9047), famotidine injection (J3490), injection diphenhydramine hcl up to 50 mg (J1200), injection dexamethasone sodium phosphate (J1100) have been met. Therefore, we decided that the Plan has to pre-approve daratumumab/hyaluronidase-fihj (J9144), carfilzomib (J9047), famotidine injection (J3490), injection diphenhydramine hcl up to 50 mg (J1200), injection dexamethasone sodium phosphate (J1100).
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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy visits provided on March 10, 2021 to March 19, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the psychotherapy visits. You say that the service was provided with no adequate time frame to obtain authorization for the service. You say the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 did not pre-approve the item/service at issue. The records provided for review do not show that the services at issue were urgent or emergent. 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 psychotherapy visits provided on March 10, 2021 to March 19, 2021 by an out-of-network (OON) provider
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from March 10, 2021,
through March 12, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient hospital care was
medically necessary. The Plan denied your request. The Plan says that the care could have been provided at a
lower level.
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 supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found 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 been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided from March 10, 2021, through March 12, 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH Admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee can receive the same services at the current 
level of care. 
 
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 documentation does not support that the enrollee in this case requires services at 
the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no 
required medical services identified that are available at the LTACH, that are not available at the current health 
care setting being offered by the health plan. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve rocker bottom for total contact ankle foot orthosis (L2232). You say that you are unable to walk without these items affixed to your shoes. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a quantity limit exception for the Dexcom G6 
Transmitter. 
 
You asked the Plan to pre-approve a quantity limit exception for the Dexcom G6 Transmitter. You say that this 
request is medically necessary. The Plan denied your request. The Plan says there are no records which support 
the quantity limit exception. 
 
The Plan must follow Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, 
must furnish to the intermediary or carrier sufficient information to determine whether coverage can be 
approved. 
 
We looked at the file and Medicare rules. In this case, there are no records supporting the request for the 
quantity limit exception. Based on this information, we decided that Medicare rules for coverage of a quantity 
limit exception for the Dexcom G6 Transmitter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a quantity limit exception for the Dexcom G6 Transmitter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (36415, 80053, 85025) and the outpatient clinic visit (G0463) rendered by the out-of-network (OON) provider on April 23, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services (36415, 80053, 85025) and the outpatient clinic visit (G0463) rendered by the out-of-network (OON) provider on April 23, 2020.