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

We decided that the Plan does not have to pay for the emergency room (ER) services 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 procedure code 99283 is not supported.

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 99283 is Level 3 emergency department visit for
evaluation and management of patient with problem of moderate severity, including expanded problem-focused
history and physical examination, and medical decision-making of moderate complexity.

We find that CPT code 99283 is not supported in the medical record. Specifically, the records do not support
Level 3 complexity of services. 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 emergency
room (ER) services rendered.
Appeal type: Drugs
Decision: Partially Favorable

We decided that the Plan has to pre-approve Gemzar and cisplatin. We decided that the Plan does not have to pre-approve nivolumab.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan says that the services are not medically necessary.
We decided that the Plan has to pre-approve Gemzar and cisplatin.
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 these services. Our reviewer says that the Gemzar and cisplatin are medically necessary. Our physician reviewer found Cisplatin and Gemzar are a standard chemotherapy regimen in the treatment of advanced bladder cancer. The enrollee is receiving neoadjuvant chemotherapy and is presumably not felt to be able to tolerate more standard regimens, such as MVAC. This is a reasonable option and a standard of care. the service is reasonable and medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-approve Gemzar and cisplatin.
We also decided that the Plan does not have to pre-approve nivolumab.
The Plan must follow Medicare rules. the rules say that Original Medicare is responsible for the costs associated with clinical trials.
We looked at the file and Medicare rules. The file shows that nivolumab is being requested as part of a clinical trial. The Plan cannot approve services associated with a clinical trial. Therefore, we decided that the Plan does not have to pre-approve nivolumab.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism (E0627).

You asked the Plan to pre-approve a seat lift mechanism. You say that this item is medically necessary. The Plan denied your request. The Plan says the criteria for the seat lift mechanism have not been met.

The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above 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 seat lift mechanism. Our reviewer says that the requested item is not medically reasonable and necessary. Our physician reviewer found you are an 85-year-old female with sciatica on the right side, a failed total knee replacement, gout and morbid obesity. The documentation does not reveal that you have severe arthritis of the hip; and/or a neuromuscular disease. The records do show that a seat lift is included in the treating practitioner's course of treatment. The documentation is not clear on how the seat lift would cause improvement in your condition or arrest or retard your condition. There is no objective examination indicating you are completely incapable of standing from a chair in the home. The documentation states that you can ambulate. The criteria for the seat lift have not been met.

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 seat lift mechanism have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism (E0627).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a colonoscopy and specialist services.

You asked the Plan to waive the copayments for a colonoscopy and specialist services. You say that you feel that the services should be considered preventative. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $400 copayment for outpatient hospital surgery services. Your contract with the Plan also clearly says that you must pay a $50 copayment for specialist visits.

You had polyps removed during a colonoscopy. Therefore, the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay the $400 copayment.

You received specialist services. Therefore, you are responsible to pay the $50 copayment.

The total amount you owe is: $450.

You have been asked to pay the total copayment amount of $450 for a colonoscopy and specialist services. A colonoscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. Specialist services fall within the physician/practitioner services, including doctor's office visits 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 copayments for a colonoscopy and specialist services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature.
You asked the Plan to pre-approve a power wheelchair power seat elevation feature (E2300). You say that the enrollee needs a power wheelchair power seat elevation feature. The Plan denied your request. The Plan says a power seat elevation feature is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. A power seat elevation feature does not serve a purpose that is primarily medical in nature. This feature is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zytiga.
You asked the Plan to pre-approve Zytiga. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Zytiga.
Benefits for Zytiga may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Zostavax vaccine 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 the services are not covered.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules. 

Records do not show that you have been injured or directly exposed to any illness related to the Zostavax vaccine. Therefore, we decided that the Plan does not have to pay for the Zostavax vaccine rendered.

Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676).
You asked the Plan to pay for a pneumatic compression device. You say that this service is medically necessary for your condition. The Plan denied your request. The Plan says this is not a covered benefit because it is a preventative service.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for IRF care have 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 that 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 patient was admitted for congestive heart failure and was discharged to skilled nursing. 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.

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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lurbinectedin.
You asked the Plan to pre-approve Lurbinectedin. You say that the enrollee has exhausted all options. The Plan denied your request. The Plan says the off-label use is not supported.
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 Lurbinectedin. Our physician reviewer found that the enrollee has small cell bladder cancer. The requested use of Lurbinectedin is not FDA-approved for the enrollee's diagnosis. It is approvable only as subsequent therapy to small cell lung cancer. The requested use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Lurbinectedin have not been met. Therefore, we decided that the Plan does not have to pre-approve Lurbinectedin.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair (PWC).

You asked the Plan to pre-approve the PWC. You say that you need a power wheelchair. The Plan denied your request. The Plan says there is insufficient information regarding the type of PWC and no information from your doctor regarding your mobility needs.

The Plan must follow Medicare rules. Medicare rules say that beneficiaries or providers must submit sufficient information to the Plan to show that payment is due and that coverage criteria are met. 

In this case, a request was submitted for a PWC using a generic code which does not correspond to any specific PWC. No medical records were submitted, and it is not clear if the PWC has been ordered by your treating physician. Without a physician order specifying the type of PWC required and records supporting that coverage criteria are met, it cannot be determined that a PWC is required at this time. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair (PWC).
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 will benefit greatly from more intense therapy. The Plan denied your request. The Plan says your needs can be met in a lower level 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. Our physician reviewer found there are no complex nursing or rehabilitation needs. The patient 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 patient 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy visits.
You asked the Plan to pre-approve physical therapy. You say that you do not want the progress you have made to slip back. The Plan denied your request. The Plan says the denial of authorization for the requested additional therapy is correct.
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 physical therapy. 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 requested additional therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the Plan. You have had extensive 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 under the supervision of a therapist. You have been instructed in a home exercise program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Carboplatin and Gemcitabine.

You asked the Plan to pre-approve Carboplatin and Gemcitabine. You say that the requested Carboplatin and Gemcitabine is medically necessary. The Plan denied your request. The Plan says that the requested Carboplatin and Gemcitabine is not medically necessary.

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 Carboplatin and Gemcitabine. Our reviewer says that the requested Carboplatin and Gemcitabine is medically necessary. Our physician reviewer found the enrollee is diagnosed with bladder cancer. The use of Carboplatin and Gemcitabine for the enrollee's condition is supported by one of the major drug compendia. Per NCCN compendia, neoadjuvant carbo/gem for stage III TCC bladder cancer is 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 Carboplatin and Gemcitabine have been met. Therefore, we decided that the Plan has to pre-approve Carboplatin and Gemcitabine. 

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder testing 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 the testing is not covered.

The Plan must follow Medicare rules. The rules say that the CxBladder testing is non-covered. 

We looked at the file and Medicare rules. The test at issue is CxBladder. This test is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the dental services.

You asked the Plan to pre-approve crown - full cast noble metal (D2792) and core buildup (D2950). You say that you are in pain and need these dental services. The Plan denied your request. The Plan says the type of crown requested, and core buildup are not covered under 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 the dental services.