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

We decided that the Plan does not have to pay for the surgical preparation or creation of recipient site (15004) provided on November 23, 2020.
You asked the Plan to pay for the surgical preparation or creation of recipient site. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.
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 asked our coder 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 surgical preparation or creation of recipient site. Our reviewer says that CPT code 15004 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include sufficient documentation to validate that a surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children was performed on November 23, 2020, therefore this service cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgical preparation or creation of recipient site have not been met. Therefore, we decided that the Plan does not have to pay for the surgical preparation or creation of recipient site (15004) provided on November 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Ketamine infusion provided on March 6, 2020.
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 in July 2019; 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 provided on March 6, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the non-emergent ambulance services (A0428, A0425) provided on
March 21, 2020.
You asked the Plan to pay for the non-emergent ambulance services. You say that you would like
reconsideration because this service was medically necessary. The Plan denied your request. The Plan says that
there is no evidence that this member's life would have been endangered with use of other non-emergency
transportation.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.
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 non-emergent ambulance services. Our
reviewer says that the medical records indicate that the enrollee is alert and oriented only x 1 and that she is bed
confined. Our physician reviewer found due to her altered mental status she requires one on one supervision by
a medical staff member and would not be appropriate to be transferred via taxi, wheelchair van or stretcher van.
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 non-emergent ambulance services have not been met. Therefore, we decided
that the Plan has to pay for the non-emergent ambulance services (A0428, A0425) provided on March 21,
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve guided tissue regeneration (D4266 x 2) and bone replacement graft for ridge preservation (D7953 x 2).
You asked the Plan to pre-approve the dental services. You say that these services should be covered. The Plan denied your request. The Plan says guided tissue regeneration is not listed as a covered service. The Plan says that bone replacement graft for tissue regeneration is not listed as a covered service either.
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 guided tissue regeneration (D4266 x 2) and bone replacement graft for ridge preservation (D7953 x 2).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve an occipital nerve block.

You asked the Plan to pre-approve an occipital nerve block. The Plan denied your request. The Plan says that
this is not medically necessary.

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 an occipital nerve block. Our reviewer
says that the requested services are considered medically reasonable and necessary in this case. Our physician
reviewer found that the enrollee has pain and tenderness over the occipital. The pain is described as stabbing. A
neurologist believes that the enrollee has occipital neuralgia. She has tried Tylenol and Gabapentin for the pain
without improvement. A diagnostic occipital nerve block is the standard of care. It is medically necessary and
reasonable.

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 occipital nerve block have been met. Therefore, we decided that the Plan has
to pre-approve an occipital nerve block.

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 acute inpatient rehabilitation facility (IRF) admission
and services for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be
provided at 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. The
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for abdominal pain after
laparoscopic cholecystectomy and was treated for a bile leak and colitis. The enrollee's medical problems are
stable. 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. Our physician reviewer found
that the enrollee's 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oncology services to be provided by a tertiary provider.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the enrollee does not need a tertiary level of care.

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 requested services. Our physician reviewer found that the enrollee has stage IIIC colon cancer and is on chemotherapy. There is no indication in the medical records that standard level of care cannot be met within the network. There is no rationale for referral to tertiary level of care. The service is not reasonable or 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve oncology services to be provided by a tertiary provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular panel provided on October 24, 2020.

You asked the Plan to pay for the cardiovascular panel. You say that you would like reconsideration because
this testing was medically necessary. The Plan denied your request. The Plan says Medicare denies coverage
for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with
suspected or documented cardiovascular disease.

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 cardiovascular panel. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found there are no published guidelines or randomized data to endorse the use of genetic
screening for multiple genetic variants which are associated with predispositions to various cardiovascular
diseases. Guidelines recommend patients be assessed for clinical risk factors, standard lipid profiles and
clinical history, symptoms and signs of cardiac disease and treated appropriately with preventive measures or
disease management based on the assessed clinical cardiovascular risk.

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 cardiovascular panel have not been met. Therefore, we decided that the Plan
does not have to pay for the cardiovascular panel provided on October 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided from November 7, 2020, to November 9, 2020.
You asked the Plan to waive the copayment for emergency care. You say that you feel that you did not receive the proper treatment for your schizophrenia. 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 $120 copayment for emergency care. You have been asked to pay a $120 copayment for emergency care. Emergency care falls within the emergency care 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 emergency care provided from November 7, 2020, to November 9, 2020.
Your quality of care concerns have been handled separately by the health plan. Medicare does not permit us to make a decision on this type of complaint.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genvisc 850 (J7320).
You asked the Plan to pre-approve Genvisc 850 (J7320). You say that you want the enrollee to be treated with this drug. The Plan denied your request. The Plan says the health plan states the enrollee has not first tried and had a contraindication or intolerance to Orthovisc and Monovisc.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Genvisc 850 (J7320). Our reviewer says that the drug is not reasonable and medically necessary. Our physician reviewer found the patient has not tried and failed the required drug(s). There is no indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the patient. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Genvisc 850 (J7320) have not been met. Therefore, we decided that the Plan does not have to pre-approve Genvisc 850 (J7320).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the wound care services described by current procedural terminology (CPT) codes 15271 and 15272 provided on September 30, 2020.
You asked the Plan to pay for CPT codes 15271 and 15272. You say that the medical records support the billing of CPT codes 15271 and 15272 provided on September 30, 2020. The Plan denied your request. The Plan says that the medical records do not support the billing of CPT codes 15271 and 15272 provided on September 30, 2020.
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 15271 is Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area. The CPT Code Manual definition of code 15272 is Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary procedure). 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 CPT codes 15271 and 15272. Our reviewers says that the medical records support the billing of CPT codes 15271 and 15272 provided on September 30, 2020. Our physician reviewer found the enrollee underwent skin substitute placement on lower extremity ulcers. At issue are whether CPT codes 15271 and 15272 for the enrollee are covered services under Medicare rules. CPT code 15271 is defined as application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area. CPT code 15272 is defined as application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary procedure). In this case, the documentation indicates that approximately 32 cm2 was applied to the right malleolar wounds and 4.5 cm2 to the left and secured with layered dressing. The elements of CPT code 15771 and 15272 are 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 CPT codes 15271 and 15272 have been met. Therefore, we decided that the Plan has to pay for the wound care services described by current procedural terminology (CPT) codes 15271 and 15272 provided on September 30, 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mobile x-ray services rendered on September 16, 2020.

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 separately payable.

The Plan must follow Medicare rules. The rules say that the SNF must submit ALL Medicare claims for ALL the services that its residents receive under Part A. 

We looked at the file and Medicare rules. The enrollee was in an approved SNF stay for the date of service at issue. Payment for the services is included in the SNF consolidated billing. 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 mobile x-ray services rendered on September 16, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee is unlikely to improve in skilled rehab in a nursing facility.

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 pre-approve SNF services. Our physician reviewer found that the enrollee has no complex wound care or other skilled nursing needs. She does not require the skilled therapy services of a qualified therapist required to provide medically necessary treatment in a SNF. Skilled nursing or therapy services are not required on a daily basis in a skilled nursing facility 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
You asked the Plan to pre-approve the dental items. You say that you need new dentures. The Plan denied your request. The Plan says dentures are covered once every 5 years. The Plan says that the frequency limit 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 and dentures are listed as covered, the frequency limit has been reached. The record shows that the Plan paid for dentures that you received on April 19, 2019. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).