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

We decided that the Plan does not have to pre-approvelumbar epidural injection services.You asked the Plan to pre-approvethe lumbar epidural injection services. You say that the records provided support the need for the injection services requested.The Plan denied your request. The Plan says the injection services in dispute are 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 lumbar epidural injection services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic low back pain. She takes Gabapentin, Diclofenac and Opiates for pain. She had physical therapy in the past which made the pain worse. She has had a series of Epidural Steroid injections, one every roughly two-threemonths. Each time she gets greater than 75% pain relief. Our physician reviewer found that the request for the lumbar epidural injection services exceeds utilization limits and places the enrollee at risk for steroid related complications.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 lumbar epidural injection services have not been met.Therefore, we decided that the Plan does not have to pre-approvelumbar epidural injection services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI of the abdomen done with a silent MRI machine.

You asked the Plan to pre-approve an MRI of the abdomen done with a silent MRI machine. You say that the requested MRI of the abdomen done with a silent MRI machine is medically necessary.The Plan denied your request. The Plan says the requested MRI of the abdomen done with a silent MRI machine 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 an MRI of the abdomen done with a silent MRI machine. Our reviewer says that the requested MRI of the abdomen done with a silent MRI machine is not medically necessary. Our physician reviewer found the enrollee is with a history of irritable bowel syndrome, as well as chronic pain, asymmetric sensorineural hearing loss, tinnitus, and hyperacusis. The clinical documentation in the case file does not support that it is medically reasonable and necessary for the enrollee to have an MRI done with a silent MRI machine. If an MRI is determined to be medically reasonable and necessary for this enrollee, additional hearing protection may be considered.

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 MRI of the abdomen done with a silent MRI machine have not been met.Therefore, we decided that the Plan does not have to pre-approve an MRI of the abdomen done with a silent MRI machine.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hereditary cancer panel rendered on January 4, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were not medically necessary.The Plan must follow Medicare rules. Medicare rules say that molecular pathology services are covered when specific criteria are met.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has reported diagnoses of unspecified leukemia not having achieved remission, malignantmast cell neoplasm, and a family history of leukemia and malignant neoplasms of lymphoid, hematopoietic and related tissues. There is no clinical documentation supporting that the results of the Full Hereditary Cancer Panel testing would directly impact the treatment or management of the enrollee in this case. The documentation in the case file does not demonstrate that the Full Hereditary Cancer Panel was medically reasonable and necessary for the 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 these services have not been met.Therefore, we decided that the Plan does not have to pay forthe hereditary cancer panel rendered on January 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe teeth extraction services (D7140) provided on May 26, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forthe teeth extraction services. You say that the services provided were medically necessary.The Plan denied your request. The Plan says no benefits are available for procedures performed by OON providers.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. The Plan covers dental services when the services are performed by contracted providers. 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 Planto pay for these services.Therefore, we decided that the Plan does not have to pay forthe teeth extraction services (D7140) provided on May 26, 2020, by an out-of-network (OON) provider.Your complaint about the Plan potentially not responding to your inquiries is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types ofcomplaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day sensor.
You asked the Plan to pre-approve the Freestyle Libre 14-day sensor. You say that the requested item is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that therapeutic continuous glucose monitors and supplies are covered for certain medical indications. 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 Freestyle Libre 14-day sensor. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee is noted to have type II diabetes, for which he takes set does of insulin twice a day. How often the enrollee tests his blood glucose is not documented. There is no evidence that the enrollee uses the results of home blood glucose testing to self-adjust insulin doses multiple times per day. As such, the requested CGM is not shown to be medically necessary, reasonable or coverable.
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 Freestyle Libre 14-day sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14-day sensor.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for screening services provided to the enrollee on April 23, 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 this type of testing is not covered as a screening.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The lab services at issue were requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for screening services provided to the enrollee on April 23, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forthe emergency department visit coded 99285 and the electrocardiogram coded 93010 provided on April 8, 2020.You asked the Plan to pay forthe emergency department visit and the electrocardiogram. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services were billed incorrectly.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 99285 and 93010 are not supported in the medical record. Specifically, these codes did not include the appropriate primary, first-listed or principal diagnosis code. The coding of severe sepsis requires a minimum of 2 codes. Based on this information, we decided that Medicare rules for coverage of the emergency department visit and the electrocardiogram have not been met.Therefore, we decided that the Plan does not have to pay forthe emergency department visit coded 99285 and the electrocardiogram coded 93010 provided on April 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation with dental code D0150 
provided. 
 
You asked the Plan to pay for dental code D0150. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says you are covered for comprehensive oral 
evaluations once every three years. The Plan says that you received a comprehensive oral evaluation on 
which is less than three years ago. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, comprehensive oral evaluations are 
covered once every three years. The file shows that you received a comprehensive oral evaluation, which is less than three years ago. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation with dental code D0150 provided.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for"Tempus xT" gene panel provided to the enrollee.

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 Medicare covers next generation sequencing for cancer only when certain criteria are met. The Plan says that "Tempus  xT"gene  panel does  not  have  FDA  approva lwhich  is  required  for  coverage  under National Coverage  Determination 90.2. 

The Plan must follow Medicare rules. Medicare has specific coverage criteria for this type of testing. In this case, the records provided do not show these criteria were met at the time of service. Therefore, we decided that the Plan does not have to pay for"Tempus xT" gene panel provided to the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical pathology services coded 88305 and the decalcification procedure coded 88311

You asked the Plan to pay for the surgical pathology services and the decalcification procedure. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are a duplicate

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 88305 and 88311 are not supported in the medical record. Specifically, the documentation supports one unit of each of these codes was provided, which were previously approved and paid by the plan. The documentation does not support additional studies were provided. Based on this information, we decided that Medicare rules for coverage of the surgical pathology services and the decalcification procedure have not been met. Therefore, we decided that the Plan does not have to pay for the surgical pathology services coded 88305 and the decalcification procedure coded 88311
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forlab services, an office visit, and an X-ray provided from June 8, 2020, to August 12, 2020.You asked the Plan to waive the copayments forlab services, an office visit, and an X-ray. You say that you never paid for these services in the past and disagree with the charges.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 $20 copayment for laboratory tests and X-rays. Your contract with the Plan also clearly says that you must pay a $15 copayment for primary care visits.You received lab services, an office visit, and an X-ray from June 8, 2020, to August 12, 2020. Therefore, you are responsible to pay the total allowed amount of $90.70, which is less than the total copayment amount.  You have been asked to pay $90.70 for lab services, an office visit, and an X-ray. Lab services, and an X-ray fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. An office visit falls 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 forlab services, an office visit, and an X-ray provided from June 8, 2020, to August 12, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe limited oral evaluation (D0140), the initial periapical x-ray (D0220), the additional periapical x-ray (D0230), and the partial upper denture (D5211) provided from May 18, 2020, to May 21, 2020.You asked the Plan to pay forthe dental services. You say that the enrollee has been having severediscomfort and pain from dental issues. You say that the enrollee has attempted to call the dental provider multiple times and did not receive an answer.The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan says there are in network dentists available. The Plan also says that you must use an in network dentist in order for dental services to be covered.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 when you receive them out of network.Therefore, we decided that the Plan does not have to pay forthe limited oral evaluation (D0140), the initial periapical x-ray (D0220), the additional periapical x-ray (D0230), and the partial upper denture (D5211) provided from May 18, 2020, to May 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 24, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe medical services. You say that these services were medically necessary.The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.  The Plan says that neither the provider of service nor the referring provider is a Plan provider.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 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 forthe medical services provided on August 24, 2020 by an out of network (OON) provider
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Planhasto pay forthe definitive drug testing provided on May 27, 2020.You asked the Planto pay forthe drug testing. You say that you have submitted all requested documentation to support this claim.The Plandenied your request. The Plansaysthatrequests were made for documentation from the ordering physician, but these were not provided.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decisionto deny your request. The Plan's specific denial rationale is not supported in this case. This rationale states that the denial was upheld because the provider failed to submit documentation from this ordering physician. However, the progress note from the ordering physician is present in the file. There is an order form for this testing. The intent to perform this testing is also documented in the progress note. There is no valid rationale given to support denial of payment for this testing.Therefore, we decided that the Planhas to pay forthe definitive drug testing provided on May 27, 2020.If the Plandoes 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 toreview. The Plan has to show us the mistake and/orsend us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a participating provider on March 24, 2020.You asked the Planto waive the copayment for a specialist office visit. You say that you were never asked at the time for a copayment. You say that this caused you more pain. The Plan denied your request. The Plan says the correct copayment has been applied.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 $30 copayment for physician/practitioner services/specialist visit. You have been asked to pay a $30 copayment for a specialist office visit. The correct copayment has been applied to the services that were provided. A specialist office visit falls within the physician/practitioner services/specialist visit 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 thatthe Plan does not have to waive the copayment for a specialist office visit provided by a participating provider on March 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMs HF System.

You asked the Plan to pre-approve these 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. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has NYHA Class III congestive heart failure with preserved left ventricular ejection fraction (LVEF 60-65 percent). In this circumstance, therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one randomized prospective trial to help reduce hospital readmission compared to standard medical therapy. The efficacy of the device is uncertain and the services are considered experimental/investigational in nature. The services are 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMs HF System.
Sincerely,
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided on September 14, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forthe lab services. You say that these tests were medically necessary.The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. The Plan says that neither the lab nor the ordering provider isacontract providerwith the Plan.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 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 forthe lab services provided on September 14, 2020, by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit provided on July 8, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe office visit. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.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 forthe office visit provided on July 8, 2020 by an out of network (OON) provider.