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

We decided that the Plan does not have to pay for the Ketamine infusion.

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 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for resin-based composites (fillings) (D2392), additional intraoral x-ray images (D0230) and unspecified preventative procedures (D1999).

You asked the Plan to pay for the dental services. You say that these services should be covered because this provider is in-network. The Plan denied your request. The Plan says they agree that these services were processed as out-of-network in error. The Plan has agreed to provide coverage for some of these services, including the first x-ray image, the cleaning and the evaluation. However, an unspecified preventative procedure is not a service that is covered by Medicare or by the Plan's supplemental dental benefit, and restorations (such as fillings or composites) require 50% coinsurance when provided in-network and are limited to two procedures per year. The record indicates that you received three fillings, so one of these cannot be covered as it exceeds the maximum benefit allowed by the Plan. Additionally, you are limited to one intraoral periapical x-ray per year, and you received two. The first will be covered, however the second x-ray exceeds what is allowed by the Plan'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 or exceed what is allowed by the Plan. Unspecified preventative procedures are not covered by Medicare or by the Plan's supplemental dental benefit. Documentation was provided to show that the Plan will pay for the covered services, including the first x-ray and two fillings. However, the second x-ray image and third filling exceed the benefit's allowance. In addition, the Plan's contract states that restorative services, such as fillings (amalgams or composites) require 50% coinsurance. The Plan was billed $320 for each of the fillings, but the Plan's allowed amount for the covered fillings (the first two) is $178. You have been asked to pay $89 for each of the two allowed fillings ($178 x 50% = $89). Therefore, you have been asked to pay the correct amount for the fillings based on your contract with the Plan, and no additional payment can be made for these services.

We decided that the Plan does not have to pay for the resin-based composites (D2392), additional intraoral x-ray images (D0230) and unspecified preventative procedures (D1999).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee.

You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service has not been billed correctly.

The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, this claim was not billed with the required Q code or on the appropriate claim form. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee.
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 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 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital and underwent treatment with Levophed and broad-spectrum antibiotics. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431).

You asked the Plan to pay for the adjunctive pre-diagnostic test. You say that this service should be covered. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.

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 adjunctive pre-diagnostic test (D0431).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.

The Plan must follow Medicare rules. The rules say that an 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 that the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's needs can be met at a lower 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided by an out of network (OON) provider.

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 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 requested provider in this case is not a network provider with the Plan. The referring provider 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 laboratory services provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the set-up portable x-ray equipment services coded Q0092 and the transportation of portable x-ray equipment and personnel to home or nursing home coded R0070.

You asked the Plan to pay for the set-up portable x-ray equipment services and the transportation of portable x-ray equipment and personnel to home or nursing home. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

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 Q0092 and R0070 are not supported in the medical record. Specifically, these codes have a professional component/technical component of 1. These codes were billed in the place of service 31 (skilled nursing facility). This means that this is an inappropriate place of service billed for these services. Based on this information, we decided that Medicare rules for coverage of the set-up portable x-ray equipment services and the transportation of portable x-ray equipment and personnel to home or nursing home have not been met. Therefore, we decided that the Plan does not have to pay for the set-up portable x-ray equipment services coded Q0092 and the transportation of portable x-ray equipment and personnel to home or nursing home coded R0070.
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 a LTACH admission is medically
necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of a LTACH
admission.

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 that you are currently undergoing treatment at an acute care hospital (ACH). There is
no evidence that you require services that are not currently available. As LTACHs and ACHs are licensed to
provide the same level of care, there is no advantage in transferring you to the LTACH. You can remain at the
current acute care hospital until such time no acute services are required. You can then be transferred or
discharged to a lower level of care for any ongoing long term care needs.

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: 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 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 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 medically necessary. Our physician reviewer found the records show that you were admitted to the hospital for respiratory failure and COVID-19 pneumonia. Your medical problems are now stable and you have 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. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. 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.

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 acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. 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 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 medically necessary. Our physician reviewer found the enrollee was admitted for surgical repair of a hip fracture after a fall. Her medical problems are stable and there are no complex nursing or rehabilitation needs. She does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. There is not a reasonable expectation that the 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PET/CT scan for the enrollee.

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says further imaging may be supported if prior routine picture studies have been performed.

The Plan must follow Medicare rules. Medicare rules say that PET scans 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 the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found a PET/CT scan is not indicated for surveillance. The enrollee's non-small-cell lung cancer was negative per the CT three months earlier.

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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a PET/CT scan for the enrollee.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a balloon sinuplasty (31295).

You asked the Plan to pre-approve the sinuplasty. You say that the procedure is medically necessary. The Plan denied your request. The Plan says coverage criteria has 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 the sinuplasty. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record shows the enrollee has not been on maximal medical management prior to surgery being recommended. Azithromycin is not typically used to treat acute or chronic sinusitis. For Penicillin allergic patients such as this patient, Doxycycline is recommended. According to the records, she was not given additional antibiotics after the Azithromycin. It is not clear the enrollee has chronic sinusitis, since her symptoms have been present for 6-8 weeks. The enrollee has not tried sinus rinses or intranasal or oral steroids. 

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 sinuplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve a balloon sinuplasty (31295).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (LSO) rendered.

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 there is no valid proof of delivery.

The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery. 

We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 lumbar-sacral orthosis (LSO) rendered.
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. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

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 was admitted for surgical revision of right total knee replacement. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care 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 IRF admission and services.