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

We decided that the Plan does not have to pre-approve the tertiary care services to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve the tertiary care. You say that you would like reconsideration because you
have a port-a-cath that needs to get flushed every week and you do not want to remove it until you have been
cancer-free for five years. The Plan denied your request. The Plan says you do not meet the criteria for tertiary
care.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The provider at issue in this case is not a network provider with the Plan. 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 tertiary care. Our reviewer says that tertiary care is not medically
necessary. Our physician reviewer found you may safely receive necessary care at an in-network provider.
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 tertiary care have not been met.
The Plan has network providers available who can provide the items/services at issue in this appeal. We found
no exception that would require the Plan to pre-approve the tertiary care. Therefore, we decided that the Plan
does not have to pre-approve the tertiary care services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on April 8, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says use of moderate sedation or Monitored Anesthesia Care in this case is usually unnecessary. 
 
The Plan must follow Medicare rules. Medicare rules say that moderate sedation or MAC is not usually 
covered for lumbar epidural injections.  
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found epidural steroid injections are typically performed in an ambulatory setting without sedation and without 
the services of an anesthesiologist. There is nothing contained in the submitted documentation to warrant 
anesthesia services for this procedure. The provided medical records do not support the use of anesthesia for 
this procedure. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for anesthesia services provided to the enrollee on April 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network dermatology services on May 28, 2020. 
 
You asked the Plan to pay for out of network services. You say that this service should be covered by the Plan. 
The Plan denied your request. The Plan says you did not have prior authorization for out of network care. 
 
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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. We 
found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan 
does not have to pay for out of network dermatology services on May 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that you would like to appeal the Plan's denial 
of the services because you were under the impression that you would only have to pay a copayment. You 
asked the Plan to reconsider providing coverage. The Plan denied your request. The Plan says these services are 
not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 20, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hearing aid (V5261) provided by an out-of-network 
supplier. 
 
You asked the Plan to pre-approve the hearing aid. You say that the hearing aids are medically necessary. The 
Plan denied your request. The Plan says hearing aids must be obtained from participating providers. 
 
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 network providers. 
 
We looked at the file and the Plan's rules. The requested provider is not a participating provider. Based on this 
information, we decided that the Plan's rules for coverage of the hearing aid have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a hearing aid (V5261) provided by an out-of-network 
supplier.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat RFA of the genicular nerves. 
 
You asked the Plan to pre-approve the repeat RFA. You say that you would like reconsideration because this 
service is an effective, non-surgical treatment that will improve the member's function and quality of life. The 
Plan denied your request. The Plan says this service is not medically necessary. 
 
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 repeat RFA. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered experimental/investigational and is subject to on-going clinical trials. 
 
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 repeat RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repeat RFA of the genicular nerves.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the panoramic x-ray (D0330) and extraction (D7210) 
provided on April 29, 2020. 
 
You asked the Plan to pay for the panoramic x-ray and extraction. You say that this was a simple procedure. 
The Plan denied your request. The Plan says these services are not covered benefits. The Plan also says that 
you signed a consent that made you aware that these services are not covered under your dental coverage. 
 
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. The record shows that you signed a consent acknowledging that these 
services were not covered. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray 
(D0330) and extraction (D7210) provided on April 29, 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 the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that 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 does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. All medically necessary care is being provided in the current acute care setting. 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 health plan has approved ongoing care in the current acute care setting. 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: 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 enrollee is stable to be discharged from hospital level of care and can be taken care of at rehab. The Plan denied your request. The Plan says Medicare coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 based on the medical records provided the enrollee does not require an intensive inpatient rehabilitation therapy program. Our physician reviewer found that care at the skilled nursing facility level is more appropriate. 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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided from November 20, 2018 to January 3, 2019.
You asked the Plan to pay for the home infusion therapy services. 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. In this case, the CPT Code Manual definition of code S9328 is home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem. We find that CPT code S9328 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided from November 20, 2018 to January 3, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dosing Entyvio every 6 weeks.
You asked the Plan to pre-approve the additional Entyvio. You say that you would like reconsideration because this drug and dosing frequency is medically necessary. The Plan denied your request. The Plan says Medicare compendia do not support dosing every 6 weeks.
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 the additional Entyvio. Our reviewer says that based on the medical records provided there is no documentation that dosing Entyvio every 6 weeks is medically reasonable and necessary. None of the Medicare-approved compendia endorse dosing Entyvio every 6 weeks for the treatment of ulcerative colitis. Our physician reviewer found there is no documentation that dosing Entyvio every 6 weeks is safe and effective. 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 additional Entyvio have not been met. Therefore, we decided that the Plan does not have to pre-approve dosing Entyvio every 6 weeks.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the fluoroscopic guidance for imaging 
services rendered on April 8, 2020. 
 
You asked the Plan to waive the coinsurance for these services. You say that you should have only a $10 
copayment for an x-ray. The Plan denied your request. The Plan says the coinsurance was 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 20% 
coinsurance for other diagnostic procedures and tests.  
 
Review of the file shows that you received advanced imaging services requiring fluoroscopic guidance on April 
8, 2020. You have been asked to pay a 20% coinsurance for these services, for a total of $25.49. These services 
fall within the other diagnostic procedures and tests 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 
coinsurance for the fluoroscopic guidance for imaging services rendered on April 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on March 13, 
2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. We 
found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan 
does not have to pay for physician services provided to the enrollee on March 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on February 18, 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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on February 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit (J0885). 
 
You asked the Plan to pre-approve Procrit. The Plan denied your request. The Plan says the off-label use of this 
drug for the enrollee's condition is not medically accepted per Medicare rules and is not covered based on the 
available information. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Procrit. Our reviewer says that Procrit 
does not meet the Plan's coverage criteria. Our physician reviewer found the requested use of Procrit (J0885) is 
not food and drug administration (FDA)-approved for the enrollee's diagnosis. Our reviewer found that the use 
of Procrit is not supported by one of the major drug compendia. Our physician reviewer also found that Procrit 
is not 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 Procrit have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Procrit (J0885).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 home health physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 3 home health PT visits. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 3 home health PT visits. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the requested therapy is not 
generally accepted as specific and effective therapy for the enrollee's condition. The enrollee's functional level 
does not require ongoing skilled services. The enrollee was noted to have some non-compliance in therapy but 
also noted to show 100% correct technique during return demonstrations. Services do not need to safely and 
effectively be performed only by a therapist, or under the supervision of a therapist. The enrollee has had prior 
therapy and was trained in a home exercise program. The requested services are not part of a maintenance 
program and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, 
design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further 
deterioration. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 3 home health PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 3 home health physical therapy (PT) visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99308) provided on December 2, 
2019 to January 22, 2020. 
 
You asked the Plan to pay for the nursing facility care. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services were not emergent or pre-authorized. There were network 
providers available. 
 
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 has network providers 
available who can provide 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 nursing facility care (99308) provided on 
December 2, 2019 to January 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-ray-each additional image provided on March 18, 2020. You asked the Plan to pay for the intraoral x-ray-each additional image. You say that you didn't know about finding out prices of services prior. You say that the claim should be reconsidered. The Plan denied your request. The Plan says one intraoral x-ray is allowed per calendar year. 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 Plan also has a maximum benefit of one intraoral x-ray per calendar year. The Plan paid for the first intraoral x-ray provided on March 18, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the intraoral x-ray-each additional image provided on March 18, 2020.