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

We decided that the Plan does not have to pre-approve a ketamine infusion.

You asked the Plan to pre-approve the infusion. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered investigational.

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 the infusion. Our reviewer says that the requested infusion is not medically reasonable or necessary. Our physician reviewer found the literature states that for spinal cord injury pain, there is weak evidence supporting ketamine infusions (0.42 mg/kg per hour to 0.4 mg/kg ranging from 17 minutes to 5 hours for 7 consecutive days) for short-term improvements in pain. For complex regional pain syndrome (CRPS), there is moderate evidence supporting ketamine infusions (22 mg/h for 4 days or 0.35 mg/kg per hour over 4 hours daily for 10 days) to provide improvements in pain for up to 12 weeks. For mixed neuropathic pain, phantom limb pain (PLP), postherpetic neuralgia (PHN), fibromyalgia, cancer pain, ischemic pain, migraine headache, and low-back pain, there is weak or no evidence supporting ketamine infusions for immediate improvements in pain. Excluding CRPS, there was no evidence supporting ketamine infusions for intermediate or long-term improvements in pain. 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 infusion have not been met. Therefore, we decided that the Plan does not have to pre-approve a ketamine infusion.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the plan will continue to pay for a higher level of care until the enrollee is medically stable to safely discharge to a skilled nursing facility.

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 he is 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650).

You asked the Plan to pay for the lumbar-sacral orthosis. You say that the orthosis was medically necessary for the enrollee. The Plan denied your request. The Plan says there is no evidence of a relationship between the prescribing physician and the enrollee.

The Plan follows Medicare rules. Medicare rules say that a spinal orthosis is subject to the coverage 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 lumbar-sacral orthosis. Our reviewer says that the requested item was not medically reasonable and necessary. Our physician reviewer found an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible evaluation and a credible physical examination of the back.

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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture provided on July 17, 2020, to October 30, 2020 by an out of network provider.
You asked the Plan to pay for acupuncture. You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request 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 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 acupuncture provided on July 17, 2020, to October 30, 2020 by an out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection and copayment for an outpatient surgery provided by a participating provider.

We decided that the Plan does not have to waive the coinsurance for an injection and copayment for an outpatient surgery provided by a participating provider

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 20% coinsurance for Medicare Part B prescription drugs/in-network and a $400 copayment for an outpatient surgery/in-network.

You have been asked to pay a 20% coinsurance of the allowed amount for an injection and $304.97 which is less than your copayment amount of $400 for an outpatient surgery. The total allowed amount is $1,086.15. You are being asked to pay $217.23 ($1,086.15 x 20% = $217.23) for an injection. The total amount you are being asked to pay is $522.20 ($217.23 + $304.97 = $522.20). An injection falls within the Medicare Part B prescription drugs/in-network benefit category and outpatient surgery 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 coinsurance for an injection and copayment for an outpatient surgery provided by a participating provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve whole body bone/joint imaging for the enrollee.

You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your request. The Plan says that there is insufficient information about what disease process might be expected based on the requested bone scan.

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 imaging. Our reviewer says that the requested imaging is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has multiple somatic complaints including polyarthralgia and headaches. The MRI of the brain done showed an abnormal appearance of the clivus including abnormal gadolinium enhancement. A radionuclide bone scan would be beneficial in order to evaluate the clivus. While chordoma is an unusual lesion the description of the clivus on the MRI deserves additional attention and radionuclide bone scan would provide further information. In addition, the enrollee suffers from polyarthralgia and fibromyalgia. While serologic markers including rheumatoid factor, ESR and CRP have not been drawn the bone scan will give important information concerning her painful joints.

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 imaging have been met. Therefore, we decided that the Plan has to pre-approve whole body bone/joint imaging 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the replacement of a failed dental implant (D6114, 21249, D7140).

You asked the Plan to pre-approve the replacement of a failed dental implant. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve the replacement of a failed dental implant (D6114, 21249, D7140).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the dynamic adjustable knee extension / flexion device (E1810) provided May 28, 2020, to July 28, 2020.
You asked the Plan to pay for the dynamic adjustable knee extension / flexion device. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the records do not support the service billed.
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 dynamic adjustable knee extension / flexion device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested item exceeds the patient's medical need as the physician documentation does not support that this device is included in the plan of care or is medically necessary for the patient's condition. 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 dynamic adjustable knee extension / flexion device have not been met. Therefore, we decided that the Plan does not have to pay for the dynamic adjustable knee extension / flexion device (E1810) provided May 28, 2020, to July 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the
setting of spinal fusion surgery has not been demonstrated in the peer-reviewed literature.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Bone marrow
aspirate remains experimental in cases of spinal fusion. More research is needed to show safety and efficacy of
bone marrow aspirate. Iliac crest autogenous bone graft remains the gold standard. Our physician reviewer
found that your condition does not meet Medicare criteria for these services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve bone marrow aspirate.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided by an OON provider.

You asked the Plan to pay for lab work. You say that these were time sensitive lab tests that were sent to you
by the referring provider. You say that you would like this claim reprocessed and paid. The Plan denied your
request. The Plan says prior authorization was not obtained by a participating provider.

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 lab work provided by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81413, 81411, 81238, 81404, 81405, 81406,
81407, 81408, 81411, 81413).

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the service is not covered.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular
risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented
cardiovascular disease.

We looked at the file and Medicare rules. The testing performed was a cardiovascular risk assessment panel
and is not covered. 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 lab services (81413, 81411,
81238, 81404, 81405, 81406, 81407, 81408, 81411, 81413).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (86780).

You asked the Plan to pay for the lab services. You say that the testing was medically necessary. The Plan
denied your request. The Plan says no medical records were provided to support that the enrollee met coverage
criteria for this service.

The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is
due and the amount of payment.

We looked at the file and Medicare rules. Insufficient medical records were provided to determine if the service
was medically necessary. 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 lab services (86780).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, bitewings, and prophylaxis provided on November 17, 2020.
You asked the Plan to pay for the periodic oral evaluation, bitewings, and prophylaxis. You say that you would like these services to be covered. The Plan denied your request. The Plan says your maximum benefit has been paid.
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 a $100 annual dental benefit maximum. The record shows that you met the annual maximum benefit on January 9, 2020 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, bitewings, and prophylaxis provided on November 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation of a portable x-ray (R0070) provided on
September 16, 2020.
You asked the Plan to pay for the transportation of a portable x-ray. You say that you would like
reconsideration because these services were medically necessary. The Plan denied your request. The Plan says
the member was not in Skilled Nursing Facility as a result provider should bill POS 32 for the services to be
covered.
The Plan must follow Medicare rules. Medicare rules say that if the patient is in a Part A SNF stay, the
transportation and set up costs are subject to consolidated billing and not separately billable to Medicare Part B.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the transportation of a portable x-ray have not been met. Specifically, the submitted claim was
billed with place of service code 31 indicating that the member was in a Part A covered Skilled Nursing
Facility stay. The billed services are subject to consolidated billing and not separately billable to Medicare Part
B. Please note, if the member was not in a Part A covered stay, the claim should be billed with a more
appropriate place of service code. Therefore, we decided that the Plan does not have to pay for the
transportation of a portable x-ray (R0070) provided on September 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a biopsy provided on October 26, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the biopsy. You say that it is the responsibility of the referring provider to get the necessary authorization. You say the referring provider stated that an authorization was not needed. 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 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 biopsy provided on October 26, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.
You asked the Plan to pre-approve power wheelchair. You say that your home situation has changed since your previous evaluation. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because you can propel yourself with a manual wheelchair and do not need a power wheelchair.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 power wheelchair. Our reviewer says that you do not meet the Medicare criteria for the requested power mobility device. Our physician reviewer found you have a personal mobility deficit, but the documentation indicates that you can ameliorate your mobility deficit with a manual wheelchair. The requested power wheelchair is not 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 power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services provided January 23, 2020 to January 29, 2020.
You asked the Plan to waive the copayment for the skilled nursing facility services. You say that you didn't know you would be admitted to the SNF and the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was 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 50% coinsurance for Skilled nursing facility (SNF) care days 21-100. You have been asked to pay a 50% coinsurance for days 21 to 25 of SNF services, for a total of $970.00. 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 skilled nursing facility (SNF) services provided January 23, 2020 to January 29, 2020.