Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met.
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 indicating medical necessity for the requested LTACH services. 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 long term acute care hospital (LTACH) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four (4) occupational health visits (CPT code 97530), for the enrollee.

You asked the Plan to pre-approve the visits. You say that the enrollee needs therapy for continued improvement. The Plan denied your request. The Plan says the therapists' notes indicate that the enrollee has not made progress on any of these goals after June 7, 2021. The Plan states the enrollee appears to have reached a level indicative of maintenance therapy and maintenance therapy is not a covered Medicare benefit.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

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 visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee has been authorized an additional 4 sessions of occupational therapy (OT) which should be sufficient to instruct on a home exercise program. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 

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 visits have not been met. Therefore, we decided that the Plan does not have to pre-approve four (4) occupational health visits (CPT code 97530), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device and related accessory provided November 12, 2020.
You asked the Plan to pay for the pneumatic compression device and related accessory. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the claim is missing required documentation.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. In this case, the medical records do not contain evidence that the prescribing physician discussed the need for the billed equipment with the enrollee. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device and related accessory provided November 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (CPT 73523) provided to the enrollee on December 28, 2020.

You asked the Plan to pay for the services. You say that the diagnosis was appropriate for this date of service. The Plan denied your request. The Plan says it is not appropriate to report unspecified, or left and right diagnosis codes when a more specific (e.g. bilateral) code is available.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 73523 is "Radiological examination, hips, bilateral." 

The ICD-10 definition of the denied diagnosis codes is:

M16.11: 

Unilateral primary osteoarthritis, right hip

M16.12:

Unilateral primary osteoarthritis, left hip

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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found it is not appropriate to report unspecified, or left and right diagnosis codes when a more specific (e.g. bilateral) code is available.

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 services have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (CPT 73523) provided to the enrollee on December 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on October 26, 2020, and October 29, 2020.
You asked the Plan to pay for the lab services. You say that the providers will not treat the enrollee due to her outstanding bills. The Plan denied your request. The Plan says the claims processed correctly.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has requested billing documents from the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the lab services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the lab services provided on October 26, 2020, and October 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay for diagnostic imaging provided to the enrollee on October 31, 2020.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says this is an administrative determination for billing and is not based on clinical criteria for
medical necessity. The Plan states this is an appeal for payment of a professional interpretation of radiologic
examination, chest, code 71045-26. However, there is no documentation supporting the imaging study which
was billed. The Plan states several attempts were made for additional information, but none was received.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes. In this case, the records provided do not support the
services billed. Medicare rules for coverage of these services have not been met. Therefore, we decided that the
Plan does not have to pay for diagnostic imaging provided to the enrollee on October 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an OmniSeq test.

You asked the Plan to pre-approve an OmniSeq test. You say that the requested testing is medically necessary. The Plan denied your request. The Plan says the clinical utility of the requested test is not established, and the documentation does not indicate how the results would impact 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 an OmniSeq test. Our reviewer says that an OmniSeq test is not considered medically reasonable and necessary in this case. Our physician reviewer found the available documentation does not demonstrate that OmniSeq Insight Panel testing will directly impact treatment or management of the enrollee in this case. Additionally, it has not been shown that the number of genes in the OmniSeq Insight Panel is reasonable and necessary to obtain the necessary information for therapeutic decision making.

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 OmniSeq test have not been met. Therefore, we decided that the Plan does not have to pre-approve an OmniSeq test.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visits to be provided by an out-of-network provider.

You asked the Plan to pre-approve the office visits. You say that you need the procedure completed and need the insurance to pay for it. The Plan denied your request. The Plan says there are providers available in-network that can and are ready to provide the care at this time.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the office visits to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation (D9310).
You asked the Plan to pre-approve the dental service. You say that you need this service. The Plan denied your request. The Plan says consultation is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a consultation (D9310).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on November 11, 2020.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for 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 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 service 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 out of network physician services provided to the enrollee on November 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on
May 6, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for 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 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 service 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 out of network physician services provided to the enrollee on May 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete denture - maxillary (CPT code D5110) and mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (CPT code D5214).
You asked the Plan to pre-approve the dental services. You say that you currently do not have any teeth/dentures to properly chew your food and is causing you to be malnourished. The Plan denied your request. The Plan says your benefit has been exhausted.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Review of the file shows you received CPT code(s): D5110 and D5214 on March 24, 2021. Additionally, we were advised that adjustments were made on July, 27, 2021, but you have not yet gone back to pick up the dentures. The dental office advised that they were closed the first two (2) weeks of August and will reopen on August 16, 2021, and you can pick up your dentures then. Moreover, the dental office  is willing to assist with any additional issues you are currently having with your dentures. Therefore, we decided that the Plan does not have to pre-approve complete denture - maxillary (CPT code D5110) and mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (CPT code D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation, per site (D7953) for tooth #14.
You asked the Plan to pre-approve the bone replacement graft. You say that you understand this service is not usually covered, but request that the Plan pay for it because it is a necessary part of your upcoming procedure. The Plan denied your request. The Plan says this service is not covered by your dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation, per site (D7953) for tooth #14.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the CT scan (74261) provided to the enrollee on October 27, 2020.
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your request. The Plan says that Current Procedural Terminology (CPT) code 74261 (1 unit) remains not supported.
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. The plan has not substantiated their denial and provided the appropriate medical records for review. The case file narrative shows that the provider enclosed radiology reports for the plan's review. There was no radiology report provided for review to the IRE. Therefore, we decided that the Plan has to pay for the CT scan (74261) provided to the enrollee on October 27, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intravenous ketamine infusion.
You asked the Plan to pre-approve intravenous ketamine infusion. You say that this request is medically necessary. The Plan denied your request. The Plan says the requested drug treatment is still considered experimental at this time for your condition.
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 intravenous ketamine infusion. Our reviewer says that the requested drug is not medically necessary and reasonable for the enrollee's condition. Our physician reviewer found the enrollee is a 38-year-old female with chronic pain secondary to fibromyalgia. Ketamine has been used to manage pain in a variety of conditions all related to chronic pain. However, clinical studies have shown varying outcomes. Multiple professional organizations, including the American Society of Regional Anesthesia and Pain Medicine (ASRA), the American Academy of Pain Medicine (AAPM), and the American Society of Anesthesiologists (ASA), have agreed that the collective evidence has shown weak to moderate support for ketamine's role in managing pain for these conditions. In this case, the review has determined that the documentation does not support that Ketamine is medically reasonable or necessary for this patient. In addition, the documentation does not support that Ketamine is safe and effective for the patient.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of intravenous ketamine infusion have not been met. Therefore, we decided that the Plan does not have to pre-approve intravenous ketamine infusion.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 17, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the enrollee enrolled in hospice from October 
8, 2020 through March 30, 2021. The Plan says, per Medicare guidelines, the provider needs to bill Original 
Medicare for the services provided on February 17, 2021. 
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 laboratory services provided on February 17, 2021.