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

We decided that the Plan does not have to pay for drug testing provided on July 15, 2020.

You asked the Plan to pay for drug tests. 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 documentation submitted does not support the Place of Service (POS) code billed on this claim.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).

We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing was taken in an office setting, therefore the Place of Service (POS) code 81 - indicating an independent laboratory setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on July 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient care provided from July 4, 2020, to July 6, 2020.
You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says the enrollee was stable for transfer.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.
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 inpatient care. Our reviewer says that the requested inpatient care is not medically reasonable and necessary. Our physician reviewer found that all inpatient care provided after 1:21 pm on July 4, 2020 was not needed on an emergent basis. As of this time, the enrollee was hemodynamcially and neurologically stable and appropriate for ambulance transport with monitoring to a Plan facility for observation/admission level of care services. The post-stabilization care services after 1:21 pm on July 4, 2020 were not medically necessary or reasonable. The treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of 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 inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient care provided from July 4, 2020, to July 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Sacroiliac Joint Injection.

You asked the Plan to pre-approve the Sacroiliac Joint Injection. You say that you would like reconsideration
because the member needs these injections to prevent further medical issues. The Plan denied your request. The
Plan says the documentation does not show that the member followed up with conservative treatment.

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 Sacroiliac Joint Injection. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the member has not had an adequate trial of physical therapy or other
conservative therapy. The documentation of SI testing maneuvers is also lacking.

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 Sacroiliac Joint Injection have not been met. Therefore, we decided that the
Plan does not have to pre-approve the Sacroiliac Joint Injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided October 9, 2020.
You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the items provided were medically necessary and reasonable. The Plan denied your request. The Plan says this patient did not receive video or telephonic visit by the ordering physician in order to warrant the codes billed.
The Plan follows Medicare rules. Medicare rules say that the knee orthosis and suspension sleeve are subject to the criteria listed 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 pay for the knee orthosis and suspension sleeve. Our reviewer says that the requested items were not medically reasonable and necessary. Our physician reviewer found there is no documentation of recent injury to, or recent surgical procedure on the enrollee's knee, there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. Claims for L1833 will be denied as not reasonable and necessary when the beneficiary does not meet the above criteria for coverage. For example, they will be denied if only pain or a subjective description of joint instability is documented. In addition, the item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided October 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardio screen of 117 genes provided on October 31, 2020.

You asked the Plan to pay for the cardiovascular risk genetic testing. You say that it is felt that this is medically necessary testing.The Plan denied your request. The Plan says this is not covered by Medicare.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

This testing was provided for an enrollee with only family history of heart disease. There is no evidence this testing was requested in order to guide treatment. As such, it is considered screening. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay for the hereditary cardio screen of 117 genes provided on October 31, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the foot x-ray (73620) provided on December 22, 2020.

You asked the Plan to pay for the foot x-ray. You say that you would like reconsideration because the member
had multiple exams on the same date of service. The Plan denied your request. The Plan says since this service
was already paid on the originally submitted (referring) claim for both the right and left foot, additional
reimbursement is not appropriate.

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 the foot x-ray. Our reviewer says that the
documentation does not support that additional units of 73620 were medically reasonable and necessary. Our
physician reviewer found CPT code 73620 has a MUE of 2 and MAI of 3 meaning that additional units are
only reimbursable when medical necessity is clearly indicated in the medical records. This service was already
paid for both the right and left foot and additional reimbursement is not appropriate.

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 foot x-ray have not been met. Therefore, we decided that the Plan does not
have to pay for the foot x-ray (73620) provided on December 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve Euflexxa. You say that the requested Euflexxa is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for Euflexxa.
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 Euflexxa. Our reviewer says that the enrollee does not meet criteria for Euflexxa. Our physician reviewer found the enrollee is diagnosed with osteoarthritis of the knee. There is no documentation of a trial and failure of physical therapy for knee pain. There is no documentation of a steroid injection. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tumor imaging.
You asked the Plan to pre-approve tumor imaging. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have 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 tumor imaging. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the issue in this case appears to be one of proper coding. It does not appear that the practitioner is requesting a Somatotatin Receptor Scintigraphy scan, but rather a tagged white blood cell scan. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of tumor imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve tumor imaging.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Ketamine infusion provided on August 14, 2020.

You asked the Plan to pay for the Ketamine infusion. You say that Ketamine infusions are a necessary treatment. The Plan denied your request. The Plan says there is not enough medical proof that shows the safety and/or success of Ketamine infusions for the treatment of depression.

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 pay for Ketamine infusion. Our reviewer says that the infusion was not medically necessary. Our physician reviewer found in July 2019; the International Anesthesia Research Society published the results of a systematic literature review which compiled the results from seven randomized controlled trials evaluating the long-term effectiveness of ketamine infusion for the treatment of pain. In total, the seven trials that were evaluated included 211 patients with three types of pain: neuropathic, mixed and nonneuropathic. Three of the seven studies reported significant analgesic benefit with ketamine, with a small analgesic effect that persisted for up to two weeks post-infusion. There was no difference in pain relief based on pain classification. The results suggested but did not establish, enhanced pain relief with higher doses of ketamine and in patients with complex regional pain syndrome. The analysis also concluded that additional studies enrolling a larger population of patients are needed in order to determine the efficacy of ketamine for chronic pain syndrome.

The review has determined that the items/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 Ketamine infusion have not been met. Therefore, we decided that the Plan does not have to pay for the Ketamine infusion provided on August 14, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the dental cleaning (D1110) provided on December 15, 2020.

You asked the Plan to pay for the cleaning. You say that you have not had another routine cleaning this year and are disappointed to see that this service is not covered. You had other services with an out-of-network provider in August, but not a routine cleaning. The Plan denied your request. The Plan says that they have already paid for a cleaning in August of 2020. Both the standard cleaning (D1110) and the periodontal maintenance (D4910) fall into the preventative/comprehensive category and therefore only one of these services are covered per year. The cleaning provided in December exceeds the frequency allowed by the Plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

The Plan denied coverage of the cleaning provided on December 15, 2020 on the basis that they already paid for a periodontal cleaning (D4910) on August 24, 2020. Documentation was provided to support this claim. The Plan states that both of these services fall into the same category. A routine cleaning is listed in the preventative/diagnostic services category, which has no additional cost-sharing for services provided in network, and a 50% coinsurance for individual services provided out of network. The documentation from the Plan shows that you were charged 75% coinsurance for the periodontal cleaning along with your deductible, which left you responsible for the full cost of the service. Only services in the basic restoration and major restoration categories have a 75% coinsurance when provided out-of-network, so it does not appear that the periodontal maintenance provided on August 24, 2020 was processed as a routine cleaning in the preventative services category. Instead, it appears that it was processed as a periodontics service in the basic restorative category.

The Plan's supplemental dental benefit includes coverage of one routine cleaning per calendar year. Based on the information provided, the Plan had not already paid for a routine cleaning for you prior to the date in question according to the contract. Therefore, we decided that the Plan has to pay for the dental cleaning (D1110) provided on December 15, 2020.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Lite test strips to be dispensed by a retail pharmacy.

You asked the Plan to pre-approve Freestyle Lite test strips. You say that the requested items are necessary for the enrollee. The Plan denied your request. The Plan says rules for coverage of diabetic test strips have not been met.

The Plan must follow Medicare rules. The rules say that MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers.

Freestyle Lite test strips are not covered by the Plan when dispensed by a retail pharmacy. Therefore, we decided that the Plan does not have to pre-approve Freestyle Lite test strips to be dispensed by a retail pharmacy.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care provided on October 6, 2020.

You asked the Plan to pay for the wound care. You say that the services were necessary. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the wound care provided on October 6, 2020.
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 enrollee does not meet criteria for IRF admission.

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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical condition does not require intensive physician or nursing supervision in an IRF. The enrollee may benefit from additional physical and occupational therapy, but the documentation does not reveal that this therapy must be only on an intensive level 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthoses (L2397, L1833) provided on October 2, 2020.

You asked the Plan to pay for the knee orthoses. You say that you would like reconsideration because these
orthoses are medically necessary. The Plan denied your request. The Plan says there is no evidence that the
member received a video or telephonic visit by the ordering physician in order to warrant the codes billed.

The Plan follows Medicare rules. Medicare rules say that a knee orthosis with adjustable knee joints is covered
if the beneficiary has had recent injury to or a surgical procedure on the knee.

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 knee orthoses. Our reviewer says that
Medicare's LCD criteria of coverage have not been met for the billed orthoses. Our physician reviewer found
the documentation does not reveal evidence of a recent surgery or injury to the knee. The documentation does
not reveal a clear documentation of specific right or left knee instability with an objective documentation of
joint laxity with a properly performed physical examination and evidence of true instability of the knees with
objective measurements.

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 knee orthoses have not been met. Therefore, we decided that the Plan does
not have to pay for knee orthoses (L2397, L1833) provided on October 2, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient rehab services provided on November 2019.

You asked the Plan to waive the copayment for the outpatient rehab services. You say that you paid more than your out-of-pocket maximum. The Plan denied your request. The Plan says the overpayment will be refunded but the cost share was correct.

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 $40 copayment for each Outpatient Rehabilitation Service.

You have been asked to pay a $40 copayment for each of the outpatient rehab services. The outpatient rehab services fall within the Outpatient Rehabilitation Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient rehab services provided on November 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81404) provided November 11, 2020.
You asked the Plan to pay for the genetic testing. You say that the lab testing was medically necessary. The Plan denied your request. The Plan says the billed services are not supported.
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. We looked at the file and Medicare rules. The plan has attested in the documentation that they contacted he treating physician who has denied ordering the tests at issue. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81404) provided November 11, 2020.