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

We decided that the Plan does not have to pre-approve IV Ketamine.

You asked the Plan to pre-approve IV Ketamine. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is experimental, and therefore, not covered.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 IV Ketamine. Our reviewer says that the drug is not medically necessary. Our physician reviewer found its requested use is not FDA approved, supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal for your diagnosis. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IV Ketamine have not been met. Specifically, this drug is not FDA approved or supported by one of the major drug compendia or CMS-approved clinical research for your diagnosis. This means the service is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve IV Ketamine.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-emergent transportation by taxi (A0100).

You asked the Plan to pre-approve non-emergent transportation. You say that the service is needed for the enrollee to maintain their appointments. The Plan denied your request. The Plan says the enrollee has exhausted their benefit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve non-emergent transportation by taxi (A0100).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the apicoectomy - anterior (D3410) received February 16, 2021.
You asked the Plan to pay for the apicoectomy. You say that the Plan offered false information about covering a percentage of endodontic procedures. The Plan denied your request. The Plan says the requested service is not covered under the enrollee's supplemental 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 pay for the apicoectomy - anterior (D3410) received February 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab testing (82175, 82300, 82495, 82728, 83036, 83655,
83825) provided July 16, 2020.
You asked the Plan to pay for the lab testing. You say that the services were medically necessary. The Plan
denied your request. The Plan says the service was provided for screening purposes and is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The test at issue in this appeal, the lab testing, was requested solely for screening purposes. Medicare does not
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab
testing (82175, 82300, 82495, 82728, 83036, 83655, 83825) provided July 16, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic activities (97530) provided on September 29, 2020.
You asked the Plan to pay for therapeutic activities. You say that this should be covered at the in-network level. The Plan denied your request. The Plan says this was not billed correctly.
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 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes.
We find that CPT code 97530 is not supported in the medical record. Specifically, the records show that this was provided in a home health setting. there is a more appropriate code for this service. Based on this information, we decided that Medicare rules for coverage of therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic activities (97530) provided on September 29, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0425, A0429) received December 29, 2020.
You asked the Plan to waive the copayment for the ambulance transportation. You say that you should not have to pay for an emergency. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 Ambulance Services. You have been asked to pay a $250 copayment for the ambulance transportation. The ambulance transportation falls within the Ambulance 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 ambulance transportation (A0425, A0429) received December 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the upper extremity.
You asked the Plan to pre-approve an MRI of the upper extremity. 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 must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI of the upper extremity. Our reviewer says that the services are not medically necessary. Our physician reviewer found the physical exam revealed normal range of motion and no red flag such as weakness or other ortho sign to mandate immediate MRI without a 6-week trial of conservative management including physical therapy (PT). Medical necessity for an MRI without 6-week trial of PT has not been established.
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 MRI of the upper extremity have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the upper extremity.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for radiation therapy services (77336, 77373) provided October 1, 2020 to
October 31, 2020.
You asked the Plan to pay for the radiation therapy services. You say that the services were medically
necessary. The Plan denied your request. The Plan says that the claim was billed without a CPT 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 codes 77336, & 77373 are supported in the medical record. Specifically, the claim shows
CPT codes 77336, & 77373 were billed. Based on this information, we decided that Medicare rules for
coverage of the radiation therapy services have been met. Therefore, we decided that the Plan has to pay for
radiation therapy services (77336, 77373) provided October 1, 2020 to October 31, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is at high risk readmission again if discharged to an inappropriate level of care. You state the enrollee is weak, fatigues easily, is malnourished and has a debilitating comorbidity of a malignancy. The Plan denied your request. The Plan says the stay is not medically necessary.
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 the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where they are currently receiving care. The documentation does not support that an additional 25 days of hospitalization are reasonably expected for the enrollee in this case. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit (99214) provided on
January 19, 2021.

You asked the Plan to waive the deductible. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the deductible has been applied correctly to the service provided.

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 $198 yearly deductible. This is the amount you must pay out of pocket before the Plan will pay their share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services. Once you have paid your deductible, the Plan will begin to pay their share of the costs for covered medical services and you will pay your copayment or coinsurance amount for the rest of the calendar year. 

You have been asked to pay $85.83 for the deductible applied for the office visit provided, as you had not previously met the yearly deductible. This amount is the Plan allowed amount for this service. 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 deductible for the office visit (99214) provided on January 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and
an intensive rehabilitation therapy program.
The enrollee does require physical and occupational therapy but there is no documented need for an intensive
rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive
rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental and investigational.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has lumbar spinal stenosis with neurogenic claudication. The provided records indicate that imaging does not demonstrate spinal stenosis at the requested area of procedure. The record does not indicate that the symptoms are improved in flexion. The elements of the coverage criteria are not satisfied. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises provided on September 10, 2020.
You asked the Plan to pay for therapeutic exercises. The Plan denied your request. The Plan says the
documentation submitted on appeal consists of duplicates of medical documents previously reviewed.
The Plan must follow Medicare rules. Medicare rules say that the provider 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. The file shows that you did not submit sufficient medical documents
to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of the
physical therapy have not been met. Therefore, we decided that the Plan does not have to pay for physical
therapy provided on September 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you feel that you would benefit from inpatient rehabilitation facility services to be able to walk better with your brace, receive hyperbaric oxygen treatments, and IV antibiotics. The Plan denied your request. The Plan says that your care can be provided safely at a less intensive setting of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. You were admitted for an infection of the left leg. Your medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH).

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 services could be provided in another setting.

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 of multiple unsuccessful weaning attempts. 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/she 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).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services provided on November 10, 2020 by an
out of network provider.
You asked the Plan to pay for the anesthesia services (01936). You say that you corrected the diagnosis code
and would like the Plan to reprocess the claim for payment. The Plan denied your request. The Plan says prior
authorization was not obtained for the non-emergent services.
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 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 the service. Therefore, we decided that
the Plan does not have to pay for anesthesia services provided on November 10, 2020 by an out of network
provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan rendered on March 22,
2021.
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 procedure code 70450 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 70450 (CT head) and 70496 (CTA head). Code 70450 is a
column II code with a modifier indicator of 1 when billed with column I code 70496. Code 70450 was not
billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not
have to pay for the computed tomography (CT) scan rendered on March 22, 2021.