Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cardiac rehabilitation visits.

You asked the Plan to waive the copayment for the cardiac rehabilitation visits. You say that you should not be
responsible for the copayments. 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 $45
copayment for each in-network Medicare-covered visit.

You have been asked to pay a $45 copayment for each of the cardiac rehabilitation visits. ($45 x 8 visits =
$360). The cardiac rehabilitation visits fall within the "Cardiac rehabilitation 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 cardiac rehabilitation visits.

Your complaint about cardiac monitor is not a valid appeal for medical coverage. This part of your complaint is
a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these
types of complaints.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Avastin (bevacizumab)as part of an anticancer chemotherapy regimen.

You asked the Plan to pre-approve Avastin (J9035). You say that you want the enrollee treated with this chemotherapy regimen. The Plan denied your request. The Plan says that Avastin used in combination with capecitabine and Folfoxiri for a diagnosis of colorectal cancer is not a medically accepted regimen.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Avastin (J9035). Our reviewer says that the drug is medically necessary. Our physician reviewer found per National Comprehensive Cancer Network (NCCN) compendia Avastin, allow Folfoxiri+Avastin as 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 Avastin (J9035) have been met. Therefore, we decided that the Plan has to pre-approve Avastin (bevacizumab)as part of an anticancer chemotherapy regimen.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pain shot.

You asked the Plan to pre-approve a pain shot. 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 facet joint injections are covered when specific
criteria are 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 pain shot. Our reviewer says that the
services are not medically necessary. Our physician reviewer found the enrollee has not had trials of
conservative therapy; Therefore, the request does not meet the criteria of the LCD and is deemed 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 a pain shot have not been met. Therefore, we decided that the Plan does not
have to pre-approve a pain shot.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical assistant services.

You asked the Plan to pay for the services provided. You say that you disagree with the decision. The Plan denied your request. The Plan says the primary procedure code was not billed.

The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered.

In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 15934. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid.

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 20700 and 20702 are add-on codes. The file does not show that the services were billed in conjunction with a valid primary procedure code. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the surgical assistant services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Ketamine Infusion Therapy provided on May 30, 2020.
You asked the Plan to pay for the Ketamine Infusion Therapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service is experimental.
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 Ketamine Infusion Therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is weak or no evidence supporting Ketamine infusions for immediate improvements in pain. 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 Ketamine Infusion Therapy have not been met. Therefore, we decided that the Plan does not have to pay for Ketamine Infusion Therapy provided on May 30, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the targeted genomic sequence analysis.

You asked the Plan to pay for the targeted genomic sequence analysis. You say that the treating physician determined that this test was medically necessary. The Plan denied your request. The Plan says a Medicare Advantage (MA) enrollee who elects hospice care, but chooses not to disenroll from the Plan, is entitled to continue to receive through the Plan any MA benefits other than those that are the responsibility of the hospice. The Plan also says that Centers for Medicare & Medicaid Services pays the MA plan, providers, and suppliers for other Medicare-covered services furnished to the enrollee through the Original Medicare program, subject to the usual rules of payment.

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 dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence analysis.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided on October 28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for radiology services. 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 or the member's primary care physician.
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 radiology services provided on October 28, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate (20939).

You asked the Plan to pre-approve bone marrow aspirate. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

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 bone marrow aspirate. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate remains experimental in spinal fusion surgery. More research is needed to show safety and efficacy. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspirate (20939).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids (V5257) and related services.

You asked the Plan to pay for the hearing aids. You say that you thought this provider was in-network and you received your previous hearing aids from them some years ago. The Plan denied your request. The Plan says they only cover hearing aids that are provided in-network. The provider you used is out-of-network. The Plan called the provider, who confirmed that they were told that the reimbursement allowance of $500 would not be covered if the hearing aids were purchased through them.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when obtained from an in-network provider.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids (V5257) and related services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee would be better served in a slower paced less intensive rehab program.
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 physician reviewer found that the enrollee was admitted to the acute care hospital for hip pain and was diagnosed with metastatic prostate cancer. His medical problems are stable. There are no complex nursing needs. There is not a reasonable expectation that he will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit and arthrocentesis provided on October 6, 2020.

You asked the Plan to waive the copayment for the office visit and arthrocentesis. You say that you were only in the office for 20 to 30 minutes and the charges are excessive. You say that you do not know how an injection is considered surgery. The Plan denied your request. The Plan says the copayments applied 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 $50 copayment for services obtained from a specialist and a $435 copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $50 copayment for the office visit and a $435 copayment for the arthrocentesis. The office visit falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The arthrocentesis falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 office visit and arthrocentesis provided on October 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided September 12, 2020.

You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the items were medically necessary. The Plan denied your request. The Plan says the patient did not receive video or telephonic visit by the ordering physician in order to warrant the code billed.

The Plan follows Medicare rules. Medicare rules say that the knee orthosis and suspension sleeve are subject to the criteria listed in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the knee orthosis and suspension sleeve. Our reviewer says that the requested items were not medically reasonable and necessary. Our physician reviewer found there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. In addition, the item coded L2397 (sleeve) is not separately payable when the base item is not covered. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided September 12, 2020.
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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 enrollee remains on high flow oxygen at 45 Liters, 50% FiO2, with diminished breath sounds and Bilevel Positive Airway Pressure (BiPAP) use at night with 60% FiO2. The enrollee has not required mechanical ventilation. The enrollee does not require services at the LTACH that are not available at the acute care hospital where the enrollee 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. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation.

You asked the Plan to pay for the comprehensive oral evaluation. You say that you did not receive an exam before your cleaning. The Plan denied your request. The Plan says your benefits for the comprehensive oral evaluation have been satisfied and the frequency limitation has been exceeded.

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, comprehensive oral evaluation is limited to one procedure every three years. The record shows that you received a comprehensive oral evaluation and your comprehensive oral evaluation benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a duplex scan.

You asked the Plan to pre-approve a duplex scan. 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 duplex scan. Our reviewer says that
the requested items/services are considered medically reasonable and necessary in this case. Our physician
reviewer found this noninvasive easily performed test is good practice and medically indicated due to the
enrollee's history and likely systemic atherosclerotic cardiovascular disease particularly important with his
smoking history.

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 duplex scan have been met. Therefore, we decided that the Plan has to preapprove
a duplex scan.

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from February 18, 2020, to March 1, 2020.
You asked the Plan to pay for the SNF services. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not require skilled service on the dates of service in this case.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the SNF services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from February 18, 2020, to March 1, 2020.