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

We decided that the Plan has to pre-approve Keytruda.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has a diagnosis of clear cell renal cell carcinoma. Keytruda is FDA-approved as first line treatment of advanced renal cell carcinoma in combination with axitinib or in combination with lenvatinib). Axitinib is on hold due to toxicities and single agent use is supported by the medical literature. The recent positron emission tomography (PET) scan showed stable disease and the criteria were not met for progression. The Keytruda is therefore reasonable and medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-approve Keytruda.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the barium swallow study provided on October 28, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the OON services. You say that you were not notified of a policy change. The Plan denied your request. The Plan says there are in-network providers who can provide the services the enrollee requires.

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 barium swallow study provided on October 28, 2020 by an out-of-network (OON) provider.
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 meets the criteria for an LTACH, and these services are medically necessary. The Plan denied your request. The Plan says the criteria for an LTACH are not met. Records indicate that the enrollee is not stable for transfer, and an LTACH does not provide a clinical advantage over a non-LTACH acute care hospital. Continued management can be provided in the current acute care hospital until the enrollee's course of care is complete.
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 necessitating admission to a LTACH. 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a ventilator (E0466), heated humidifier (E0562), and
tubing used with a positive airway pressure device (A7037).
You asked the Plan to pre-approve a ventilator and accessories. You say that the items are medically necessary.
The Plan denied your request. The Plan says the device would be used in a bi-level positive airway pressure
(BiPAP) mode.
The Plan must follow Medicare rules. Medicare rules say that claims for ventilators used to provide continuous
positive airway pressure (CPAP) or bi-level CPAP therapy for conditions described in this RAD policy will be
denied as not reasonable and necessary.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a ventilator and accessories have not been met. Therefore, we decided that the Plan does not have
to pre-approve a ventilator (E0466), heated humidifier (E0562), and tubing used with a positive airway
pressure device (A7037).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nipple revision.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied
your request. The Plan says there were no surgical complications.
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are
coverable.
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 procedure. Our reviewer says that
the requested procedure is not considered medically reasonable and necessary in this case. Our physician
reviewer found the record indicates that you underwent reductive mammoplasty in April 2021. The record
indicates a 0.5 cm difference in the sternal notch to nipple distance for each breast. The record indicates that
this limits the type of clothes you can wear. This means that the requested procedure is cosmetic in nature. The
provided records do not support the medical necessity and reasonableness, as defined by Medicare rules, of the
requested service.
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 procedure have not been met. Therefore, we decided that the Plan does not
have to pre-approve nipple revision.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Accu-Check Guide test strips.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are available from the preferred providers.
The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred providers
for durable medical equipment and supplies.
We looked at the file and Medicare rules. The services at issue are diabetic testing strips from a non-preferred
provider. The services are available from the Plan's preferred providers. Therefore, we decided that the Plan
does not have to pre-approve Accu-Check Guide test strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral periapical radiographic image (D0220), provided on May 6, 2021.
You asked the Plan to pay for the intraoral periapical radiographic image. You say that the services should be covered. The Plan denied your request. The Plan says you received the services through an out-of-network provider.
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. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Specifically, you received the services from an out-of-network provider. This means the service is not covered. Therefore, we decided that the Plan does not have to pay for the intraoral periapical radiographic image (D0220), provided on May 6, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve transcatheter placement of an intravascular stent for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says that this request is investigational.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 procedure. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found there is documentation of severe whole leg edema of the right lower extremity with a large ulcer that appears to be venous in nature. Arterial perfusion appears to be satisfactory. There is documentation of a significant stenosis in the right external iliac vein. It is reasonable and medically necessary to attempt to improve the venous outflow with venous angioplasty and stenting of this narrowed area. 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 procedure have been met. Therefore, we decided that the Plan has to pre-approve transcatheter placement of an intravascular stent 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says another treatment is not medically necessary and cannot be approved at this time.
The Plan must follow Medicare rules. The rules say that no more than two radiofrequency sessions can be covered per rolling 12 months. The records show that the enrollee received RFA on December 16, 2020 and July 21, 2021. The enrollee would not be able to receive this service again until December 16, 2021. 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 radiofrequency ablation for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve attendant care service (S5125).
You asked the Plan to pre-approve the attendant care service. You say that you cannot remember to take any medicine the right way. You also say that you are either taking too much or not enough because of your brain injury, and you also need help with mobility. The Plan denied your request. The Plan says this service is not a covered benefit.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the attendant care service have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve attendant care service (S5125).
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for the interpretation of the duplex scan of the extremity veins provided on August 7, 2020, during an inpatient stay.
You asked the Plan to pay for the duplex scan interpretation. You say that this was correctly coded and should be paid. The Plan denied your request. The Plan says that payment for all services rendered to an inpatient are included in the payment to the facility. No separate payment can be made for this service.
The Plan must follow Medicare rules. Medicare rules say that only items and non-physician services are bundled into the inpatient PPS. Physician services are exempted and are separately payable. The professional component of diagnostic testing is solely a physician service. Only the technical component would be bundled with payment to the facility. In this case, the billing physician did not bill for the technical component of this service. Therefore, we decided that the Plan has to pay for the interpretation of the duplex scan of the extremity veins provided on August 7, 2020, during an inpatient stay.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an oxygen concentrator (E1390) provided on January 13, 2021.
You asked the Plan to pay for an oxygen concentrator. You say that, according to the Medicare.com website, you are fully covered for the expense in dispute. The Plan denied your request. The Plan says rules for oxygen equipment have not been met.
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for coverage. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an oxygen concentrator have not been met. Specifically, the request is not for rented oxygen equipment as the oxygen concentrator at issue was purchased. Therefore, we decided that the Plan does not have to pay for an oxygen concentrator (E1390) provided on January 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve molecular genetic testing.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says based on a review of the existing evidence, there are currently no clinical indications for this technology.
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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the clinical utility of genetic testing depends on the ability of testing results to change management that results in improved clinical outcomes. The clinical utility of genetic testing for thrombophilia is based on the overall risk of thromboembolism and the risk/benefit ratio of treatment, primarily with anticoagulants. In this case, the test is being requested for the treatment of hyperlipidemia. The review has determined that the services at issue in this case are 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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve molecular genetic testing.
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 inpatient rehabilitation is medically necessary, and the enrollee would benefit from these services to maximize their safety and independence with functional mobility at home. The Plan denied your request. The Plan says the criteria for an IRF are not met. The enrollee does need therapy, but these services can be provided at a lower 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 30, 2020.
You asked the Plan to pay for the lab services. You say that the lab is obligated to process specimens it
receives. The Plan denied your request. The Plan says the billed codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.
We looked at the file and the rules. The claim provided shows a place of service of an independent laboratory. The records do not indicate the specimen was obtained at an independent laboratory. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on August 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extractions (D7210) provided on March 5, 2021.
You asked the Plan to pay for the surgical extractions. You say that you had carcinoma cancer and your teeth decayed. The Plan denied your request. The Plan says your contract does not cover this service.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. The record shows that you have had a past history of radiation, and that these extractions were not in preparation for radiation. Therefore, we decided that the Plan does not have to pay for the surgical extractions (D7210) provided on March 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the deep sedation/general anesthesia - first 15 minutes
(D9222) and unspecified preventive procedure, by report (D1999) provided January 21, 2021.
You asked the Plan to pay for the anesthesia and unspecified preventative procedure. You say that you already
paid $150 and you don't feel you should be responsible for the remaining charge. The Plan denied your request.
The Plan says these services are not covered under your benefits.
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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the deep
sedation/general anesthesia - first 15 minutes (D9222) and unspecified preventive procedure, by report (D1999) provided January 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for non-face-to-face prolonged service (99358) provided April 2, 2021 to April 6, 2021.
You asked the Plan to pay for non-face-to-face prolonged service. You say that please see enclosed medical records that support services billed and reconsider the denial. The Plan denied your request. The Plan says this code is not supported by the documentation provided.
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 99358 is prolonged evaluation and management service before and/or after direct patient care, first hour). We find that CPT code 99358 is not supported in the medical record. Specifically, code 99358 is used to report pre-service or post-service work performed as part of a face-to-face service. In this case, the documentation shows a service on April 2, 2021, April 5, 2021 and April 6, 2021 that is separate from the face-to-face service on April 1, 2021. The documentation on April 2, 2021, April 5, 2021 and April 6, 2021 shows an interprofessional telephone/internet /electronic health record assessment and management service provided by a consultative physician, including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional. This service is reported with a code from the range 99446-99449. The documentation shows a hospital visit with the patient on the previous day, so the interprofessional consultation on April 2, 2021, April 5, 2021 and April 6, 2021 may not be reported separately. Based on this information, we decided that Medicare rules for coverage of non-face-to-face prolonged service have not been met. Therefore, we decided that the Plan does not have to pay for non-face-to-face prolonged service (99358) provided April 2, 2021 to April 6, 2021.