Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral evaluation (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on March 18, 2021.

You asked the Plan to pay for the dental services. You say that you have basic dental coverage. You also say that if you use and out of network dentist, you are partial covered. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services performed out of network are not covered. The Plan also says that you were not enrolled in the optional supplemental dental rider on the date of service, which would have provided out of network benefits.

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 performed out of network. The record shows that you were not enrolled in the optional supplemental dental rider which would provide out of network coverage. Therefore, we decided that the Plan does not have to pay for the oral evaluation (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on March 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out of network (OON) physical therapy services.

You asked the Plan to pre-approve the OON physical therapy services. You say that none of the Plan's in network physical therapy providers have experience with dementia patients. You say that the requested OON provider does have experience with dementia patients. The Plan denied your request. The Plan says there are in network physical therapy providers who can supply the care needed by the enrollee.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few exceptions, enrollees must use contract providers for care. 

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 OON physical therapy services. Our reviewer says that the criteria for coverage of OON care have not been met. Our physician reviewer found the documentation does not indicate that the Plan is unable to offer adequate care to meet the enrollee's medical needs through referral to physical therapy. The documentation does not reveal that there is anything unique about the enrollee's condition that that would make it medically necessary for her to see the requested OON provider. There is no evidence that the in-network providers are unable to effectively treat the enrollee for her chronic pain conditions with her history of dementia. The plan has shown that they have in-network providers who meet the standards of care required for treatment of the enrollee's condition. 

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 OON physical therapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve out of network (OON) physical therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 2, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the provider is not in-network and there is no authorization on file.
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 did not pre-approve the
physician's services. 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's services provided on November 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit provided on December 1, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the domiciliary visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 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 domiciliary visit provided on December 1,
2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical spine.

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 MRIs are covered only when they are medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee is documented to have one month of neck pain that is improved with muscle relaxants. Plain films were performed but the results are not documented. Physical examination demonstrates trapezius spasm and normal neurologic examination. Physical therapy has not been performed. The records do not support that the MRI is reasonable or medically necessary at this time. 

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 magnetic resonance imaging (MRI) of the cervical spine.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services provided on April 16, 2020.

You asked the Plan to pay for the paramedic intercept services. You say that you believe that the additional help for your father should be covered as it was all part of the same medical emergency The Plan denied your request. The Plan says this item is not a covered benefit.

The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as defined above. It is noted that the only State in which these criteria are met is New York. 

The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the paramedic intercept services provided on April 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Octreotide scan (78804).

You asked the Plan to pre-approve an Octreotide scan. You say that this test needs to be done to make sure you do not miss anything regarding the enrollee's health care. Please consider this to be done for her care. The Plan denied your request. The Plan says the Octreotide scan is not reasonable or medically necessary as the enrollee does not meet the criteria.

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 Octreotide scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee previously had a gastrinoma that was resected, and she underwent a Bilroth I reconstruction. She subsequently required distal gastrectomy. The enrollee has dysphagia when swallowing. Endoscopy has not been performed. The record does not indicate that laboratory studies or other imaging has been performed. The records provided do not support the medical necessity or reasonableness of the requested service as defined by Medicare rules and the elements of the coverage criteria are not 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 an Octreotide scan have not been met. Therefore, we decided that the Plan does not have to pre-approve an Octreotide scan (78804).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for initial nursing facility care provided on September 21, 2020.

You asked the Plan to pay for initial nursing facility care. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services 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 initial nursing facility care provided on September 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services that you provided on February 5, 2021.
You asked the Plan to pay for the physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
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 did not pre-approve the services 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's services that you provided on February 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
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 sacroilitis. Sacral lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and investigational. Radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, 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 radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the magnetic resonance angiography (MRA) of the neck (70549).

You asked the Plan to pre-approve the MRA of the neck. You say that you respectfully request that this information is reviewed, and the prior authorization is promptly reprocessed, reconsidering for approval. The Plan denied your request. The Plan says the enrollee does not meet the coverage criteria for the requested procedure.

The Plan must follow Medicare rules. Medicare rules say that MRA's are covered only when they are medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRA of the neck. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case the enrollee's aneurysm is not considered to be at risk of rupture and there is not otherwise a clear indication for surgery at this time. The applicable LCD states: MRA is performed on patients with conditions of the head and neck for which surgery is anticipated and may be found to be appropriate based on the MRA. The enrollee has no other signs or symptomology to suggest the presence of an aneurysm in the region of the neck that would warrant or benefit from imaging at this time. There is no other symptomology present that would indicate a need for surgery. As such the requested study would not be 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 the MRA of the neck have not been met. Therefore, we decided that the Plan does not have to pre-approve the magnetic resonance angiography (MRA) of the neck (70549).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the normal saline solution infusion, Iron Dextran injection, 1 hour or less of an infusion into a vein for therapy, prevention, or diagnosis, and each additional hour of infusion into a vein for therapy, prevention, or diagnosis provided on October 26, 2020 by an OON provider.

You asked the Plan to pay for the normal saline solution infusion, Iron Dextran injection, and infusion into a vein for therapy, prevention, or diagnosis. You say that an authorization was not obtained, but the services were medically necessary. The Plan denied your request. The Plan says these services were rendered by a non-participating provider. The Plan also says that prior authorization was not obtained.

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 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 normal saline solution infusion, Iron Dextran injection, 1 hour or less of an infusion into a vein for therapy, prevention, or diagnosis, and each additional hour of infusion into a vein for therapy, prevention, or diagnosis provided on October 26, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the emergency room visit provided from February 21, 2021, to February 15, 2021.
You asked the Plan to waive the copayment for the emergency room visit. You say that you were admitted as an inpatient. The Plan denied your request. The Plan says that you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $90 copayment for emergency services at an in-network emergency room. You do not pay the emergency room visit cost share if you are admitted to the hospital within 24 hours for the same condition The Plan says you must pay a $90 copayment for the emergency room visit. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for the emergency room visit. The medical record shows you were admitted as an inpatient from your emergency room visit. Therefore, we decided that the Plan has to waive the copayment for the emergency room visit provided from February 21, 2021, to February 15, 2021.
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 chest x-ray rendered on February 10, 2021.

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 71045 is not separately payable.

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. 

The provider submitted a claim for procedure codes 71045 (chest x-ray) and 77001 (fluoroscopic guidance). Code 71045 is a column II code with a modifier indicator of 1 when billed with column I code 77001. Code 71045 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the chest x-ray rendered on February 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the injection services provided on January 25, 2021.

You asked the Plan to waive the copay for the services provided. You say that the amount you owe seems very high. The Plan denied your request. The Plan says the coinsurance was assessed correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs.

You have been asked to pay a 20% coinsurance for the services provided. The services fall within the Medicare Part B prescription drugs 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 copay for the injection services provided on January 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.

You asked the Plan to pre-approve the compression stockings. You say that the item is medically necessary. The Plan denied your request. The Plan says this is a non-covered benefit.

The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6530 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound.

The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on December 29, 2020.
You asked the Plan to pay for the services provided. You say that the enrollee was brought into the operating room two separate times. The Plan denied your request. The Plan says only the anesthesia service that has the highest base unit value should be reported.
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 looked at the file and the rules. The records show that the anesthesia procedure with the highest base unit value was billed and paid by the Plan. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on December 29, 2020.