Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to make additional payment for the diagnostic anoscopy and knee injections provided in an outpatient hospital.

You asked the Plan to make additional payment for the two outpatient hospital visits. You say that you were out of the area when you had these medical issues for which you were not able to fly home for treatment. The Plan denied your request. The Plan says it was decided that these should be covered as urgently needed out of area care. Therefore, this was paid according to the Medicare allowable and assessing the $100 outpatient hospital copayments for each visit. It was confirmed that the charges that remain denied are being written off by the hospital and will not be billed to you.

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 $100 copayment for surgery services in an outpatient hospital.

You have been asked to pay a $100 copayment for each of the two outpatient hospital visits. The services provided during these visits fall within the surgery services in an outpatient hospital 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 make additional payment for the diagnostic anoscopy and knee injections provided in an outpatient hospital.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional occupational therapy services.

You asked the Plan to pre-approve the additional occupational therapy services. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that therapy services are covered when the written plan of care incorporates those treatment elements that require services of a skilled therapist. 

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 additional occupational therapy services. Our reviewer says that the requested services are not medically necessary. Our physician reviewer found the records do not demonstrate that the unique skills of a professional therapist are required for further 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 the additional occupational therapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional occupational therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care provided by an out-of-network provider.

You asked the Plan to pay for nursing facility care. You say that the doctor should not be penalized for the hospital staff failing to obtain authorization. You say that the physician provided medically necessary services and payment should be processed. The Plan denied your request. The Plan says utilization of in network providers is 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 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 nursing facility care provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Ketamine infusion.

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 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an injection provided by a participating provider on October 14, 2020.

You asked the Plan to waive the copayment for an injection. You say that all you get is an injection in your knee. You say that this is not an outpatient surgery. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for outpatient surgery/in-network. 

You have been asked to pay a $250 copayment for an injection. The injection that was provided is considered an outpatient surgery; therefore, the correct copayment has been applied. An injection falls within the outpatient surgery/in-network 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 an injection provided by a participating provider on October 14, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services.

You asked the Plan to pay for the SNF services. You say that since the enrollee is on Medicare Advantage plan that there should be no need for an pre-authorization for the services. The Plan denied your request. The Plan says the records do not show that the enrollee required daily skilled nursing or skilled therapy in a SNF setting for the dates of service in this case. The Plan also says that custodial care is not covered by Medicare.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary.

Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.

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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (0037U) provided November 22, 2020.

You asked the Plan to pay for the genetic testing. You say that these services were medically necessary. The Plan denied your request. The Plan says coverage rules have not been met.

The Plan must follow Medicare rules. Medicare rules say that genetic testing may be covered when results of the testing will directly impact treatment. 

We looked at the file and Medicare rules. The medical records show that the patient had no intention to begin further treatment beyond radiation therapy. The records do not show that the testing would impact treatment decisions. 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 (0037U) provided November 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81479) provided August 25, 2020.

You asked the Plan to pay for the genetic testing. You say that the genetic testing was medically necessary. The
Plan denied your request. The Plan says coverage criteria was not met.

The Plan must follow Medicare rules. Medicare rules say that this type of genetic test is covered when there is
an indeterminate follicular pathology on fine needle aspiration.

We looked at the file and Medicare rules. The record shows that the pathologist was able to determine that the
tumor was consistent with a follicular neoplasm on fine needle aspiration. The results were not indeterminate as
required. 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 (81479) provided August
25, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Ziextenzo.

You asked the Plan to pre-approve Ziextenzo. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not supported.

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 Ziextenzo. Our reviewer says that the requested use of Ziextenzo meets criteria for coverage. Our physician reviewer found Ziextenzo is FDA-approved to decrease the incidence of infection (as manifested by febrile neutropenia), in patients with nonmyeloid malignancies receiving myelosuppressive cancer chemotherapy associated with a clinically significant incidence of febrile neutropenia and it is supported by one of the major drug compendia. The documentation supports that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ziextenzo have been met. Therefore, we decided that the Plan has to pre-approve Ziextenzo.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on November 7, 2019.

You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. 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 subsequent nursing facility care provided on November 7, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency care (92950, 31500, 93010, 99291).

You asked the Plan to pay for the emergency care. You say that the service was medically necessary. The Plan denied your request. The Plan says the claim did not include a valid primary diagnosis code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT code 92950, 31500, 93010, & 99291 is not supported in the medical record. Specifically, the primary diagnosis code listed requires that the underlying condition be listed first. Based on this information, we decided that Medicare rules for coverage of the emergency care have not been met. Therefore, we decided that the Plan does not have to pay for emergency care (92950, 31500, 93010, 99291).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the knee orthosis (L1833) and suspension sleeve (L2397).

You asked the Plan to pre-approve the knee orthosis and suspension sleeve. You say that the items provided were medically necessary for the enrollee. The Plan denied your request. The Plan says the patient did not receive video or telephonic visits by the ordering physician.

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 pre-approve the knee orthosis and suspension sleeve. Our reviewer says that the items provided were medically necessary. Our physician reviewer found there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. 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 pre-approve the knee orthosis (L1833) and suspension sleeve (L2397).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required and to
pay more for the crown.

You asked the Plan to pay for the core buildup or pay more for the crown. You say that you were not aware
that your maximum allowable had been reached. The Plan denied your request. The Plan says the remaining
$636 of your annual benefit was applied toward the crown service. The Plan also says that when the core 
buildup was submitted, the full $1,200.00 of the enrollee's annual maximum had been used.

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 Plan offers an annual maximum
benefit of $1,200 every year. The record shows that you met the annual maximum benefit and the enrollee's 
annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not
have to pay for the core buildup, including any pins when required and to pay more for the crown.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided by an OON provider.

You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent
nor urgent and prior authorization was not obtained to provide out-of-network care.

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 the physician services provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the crown (D2752), the cleanings (D1110 x 2), and the amalgam (D2160).

You asked the Plan to pay the in network rate for the dental services. You say that the Plan website clearly lists the provider in this case as in network. You say that you confirmed this by calling the Plan directly. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that out of network providers may bill you for any amount greater than the payment made by the Plan to the 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 and the services are listed as covered, dental services that you receive out of network may have a higher cost share. Out of network dentists may bill you for any amount greater than the payment made by the Plan to the provider. Therefore, we decided that the Plan does not have to pay the in network rate for the crown (D2752), the cleanings (D1110 x 2), and the amalgam (D2160).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided by an out of network (OON) provider.

You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and paid. You say that these services were provided in a skilled nursing facility. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider or rendered in a participating facility.

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 skilled nursing services provided by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transportation service (A0425, A0429).

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that transportation by ambulance, to and from another hospital or freestanding facility to receive specialized diagnostic or therapeutic services not available at the facility where the patient is an inpatient is considered part of the inpatient admission, and not separately payable.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Specifically, the record shows that the enrollee was an inpatient in the hospital on this date of service. Ambulance services used for the transportation of a hospital inpatient to another facility for diagnostic tests or treatment is considered part of the inpatient admission, and is not separately payable. Therefore, we decided that the Plan does not have to pay for the ambulance transportation service (A0425, A0429).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lorazepam for the enrollee.

You asked the Plan to pre-approve this drug. You say that the member needs this medication to maintain their diagnosis. The Plan denied your request. The Plan says that this is not covered under Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lorazepam for the enrollee.

Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.