Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an LSO (L0650) provided on September 21, 2020.
You asked the Plan to pay for an LSO. You say that the enrollee is using the requested medically necessary item with benefit. The Plan denied your request. The Plan says there is no documentation of a video or telephonic visit by the ordering physician to warrant the code 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 an LSO. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee's chief complaint was lower back pain. The available documentation in the case file does not support that the requested LSO was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by Medicare. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the LSO was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of an appropriate 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 an LSO have not been met. Therefore, we decided that the Plan does not have to pay for an LSO (L0650) provided on September 21, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services rendered from February 15, 2020 to March 15, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not medically necessary.
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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the most recent therapy notes indicate that the enrollee was able to ambulate up to 250 feet and was independent with most self-care tasks. Skilled services were discontinued by February 14, 2020 because her functional status was at her baseline. She did not have any complex daily wound care, parental medications, or feeding tube care. The enrollee did not require skilled nursing or skilled therapy services on a daily basis. As a practical matter, the enrollee did not require the necessary services on an inpatient basis at the SNF level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services rendered from February 15, 2020 to March 15, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing services.
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 not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 not medically necessary. Our physician reviewer found the submitted records show that you have been receiving home health skilled nursing services. The records do not support that continued services are required to improve your condition or to establish/perform a maintenance program to maintain your condition and/or prevent deterioration beyond March 30, 2021. The records indicate that, as of April 3, 2021, you are in stable condition with your goals met and maximum potential reached. Continued services are therefore not reasonable or 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 not been met. Therefore, we decided that the Plan does not have to pre-approve home health skilled nursing services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied your request. The Plan says rules for SNF care have not been met.
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 pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 66-year-old female with breast cancer and extensive bone metastases. While there are identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. In addition, the beneficiary does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) rendered by the out of network (OON) provider.

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 the service was rendered by an out of network provider, without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) rendered by the out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the visits you had with a general surgeon (a specialist).

You asked the Plan to reduce the copayments for the specialist visits. You say that you believe you should have a $40 copayment for specialist services, not a $50 copayment. The Plan denied your request. The Plan says the $50 copayment is appropriate for these services. The Plan says you changed to a different plan effective April 1, 2020. Under your new plan, there is a $50 copayment for specialist visits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for visits with a specialist.

You have been asked to pay a $50 copayment for each of the specialist visits. 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 reduce the copayments for the visits you had with a general surgeon (a specialist). We note that your appeal request also includes date of service. The Plan did not submit this date of service to us for review. Please contact the Plan directly for any appeal rights you may have regarding services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Ketamine infusion provided on April 15, 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 April 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telehealth visit you had at an outpatient specialty clinic.

You asked the Plan to waive the copayment for the telehealth visit. You say that this claim should be paid in full The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this telehealth visit ($26.65) is less than your copayment obligation, you are responsible for the full allowed amount.

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 $45 copayment for specialist services, including telehealth visits.

You have been asked to pay a $45 copayment for the telehealth visit. The telehealth visit falls within the specialist 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 the telehealth visit you had at an outpatient specialty clinic.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a Synvisc injection.
You asked the Plan to pre-approve a Synvisc injection. You say that the services are necessary. The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria have not been met.
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 a Synvisc injection. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found while cognizant of the American Academy of Orthopaedic Surgeons (AAOS) position, this is ongoing therapy and therefore, is deemed medically reasonable and 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 a Synvisc injection have been met. Therefore, we decided that the Plan has to pre-approve a Synvisc injection.
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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genvisc knee injections.
You asked the Plan to pre-approve the Genvisc injections. You say that this drug is necessary to treat the enrollee's condition. The Plan denied your request. The Plan says there is no reason that Orthovisc would not be as effective as the requested agent.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Genvisc injections. Our reviewer says that the requested drug is not considered reasonable and necessary based on Plan step therapy criteria. Our physician reviewer found the enrollee has a diagnosis of Bilateral primary osteoarthritis of the knees. The Plan requires a trial of drug Orthovisc before they will approve the requested drug. The case file does not contain documentation of trial and failure of Orthovisc. The documentation does not support that Orthovisc would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 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 Genvisc injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Genvisc knee injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a segmented compressor with calibrated gradient pressure (E0652).
You asked the Plan to pre-approve a segmented compressor with calibrated gradient pressure. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that a PCD coded as E0652, is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen when specific criteria is met.
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 a segmented compressor with calibrated gradient pressure. Our reviewer says that the item is not medically necessary. Our physician reviewer found the documentation does not reveal lymphedema extending onto the chest, trunk and/or abdomen that extends past the limits of a standard compression sleeve, and the chest, trunk and/or a four-week trial of conservative therapy demonstrating failed response to treatment with and E0650 or E0651. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a segmented compressor with calibrated gradient pressure have not been met. Therefore, we decided that the Plan does not have to pre-approve a segmented compressor with calibrated gradient pressure (E0652).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fentanyl.
You asked the Plan to pre-approve Fentanyl. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
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 Fentanyl.
Benefits for Fentanyl may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ambulance services.

You asked the Plan to waive the copayments for the ambulance services. You say that you cannot afford this cost sharing. You said that you were transferred from different facilities and it wasn't your choice. The Plan denied your request. The Plan says you were charged these copayments correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment for each one-way ambulance trip.

You have been asked to pay a $300 copayment for each of the ambulance services. These copayments apply regardless of the reason for the transport. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for ambulance services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from July 28, 2020, to August 5,2020.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were told you do not have to pay this charge because you met your deductible. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
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 per day, per stay for days 1-4 for in-network inpatient hospital care. You have been asked to pay a $233.14 copayment, which is less than the standard copayment amount, for the inpatient hospital stay. The inpatient hospital stay falls within the "Inpatient hospital care" benefit category. The record shows you met your $3,300 maximum out-of-pocket amount with this claim.
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 the inpatient hospital stay provided r from July 28, 2020, to August 5,2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the acupuncture services provided from July 21, 2020 to August 12, 2020.
You asked the Plan to pay for the acupuncture services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, we find that the Plan did not provide sufficient documentation to determine if you met Medicare criteria for the acupuncture services you received from July 21, 2020 to August 12, 2020. Medicare say for services performed on or after January 21, 2020, Medicare will now provide limited coverage of acupuncture for patients with chronic low back pain (CLBP). For the purposes of this coverage, CLBP is defined as lasting 12 or more weeks, non-specific (meaning there is no identifiable systemic cause, such as metastatic, inflammatory, infectious disease), and not associated with either surgery or pregnancy. The file does not show that the Plan made any attempts at requesting medical records to determine if you meet these Medicare criteria for your back pain. Therefore, we decided that the Plan has to pay for the acupuncture services provided from July 21, 2020 to August 12, 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.