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

We decided that the Plan does not have to pay for the lab testing services provided on October 8, 2020.

You asked the Plan to pay for the services provided. You say that the medical records show medical necessity. The Plan denied your request. The Plan says the performance of multiple molecular tests should be billed under a single CPT code.

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. If a single procedure is performed, only one HCPCS/CPT code with one unit of service may be reported for the procedure. 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 lab testing services provided on October 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve a shower chair. You say that you've been unable to bathe your entire body for over a month. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous process distraction device.

You asked the Plan to pre-approve interspinous process distraction device (C1821), insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (22870).

You say that the interspinous process spacer is a medically approved procedure by Medicare and is medically necessary in this patient. The Plan denied your request. The Plan says there are not enough studies to show the device is better than a regular spine surgery.

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 Interspinous process distraction device (C1821), insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (22870). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the vertiflex device is experimental. More research is needed to show safety and efficacy of the device.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Interspinous process distraction device (C1821), insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (22870) have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous process distraction device.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychotherapy visits provided from August 26, 2020 to November 18, 2020 by an out of network (OON) provider.

You asked the Plan to pay for psychotherapy visits. You say that you are in follow-up care and cannot start with any other healthcare professional. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and 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. Although this Plan offers a POS benefit, authorization must be obtained prior to receiving service in order for the POS benefit to cover service. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 a psychotherapy visits provided from August 26, 2020 to November 18, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), bitewing radiographic images (D0274), intraoral periapical radiographic images (D0220, D0230 x2), and a filling (D2393) provided from January 9, 2021, through January 13, 2021.

You asked the Plan to pay for a comprehensive oral evaluation, bitewing radiographic images, intraoral periapical radiographic images, and a filling. You say that you did not know that the provider was out-of-network. The Plan denied your request. The Plan says there is no coverage for when services are rendered by an out-of-network provider.

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. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation, bitewing radiographic images, intraoral periapical radiographic images, and a filling have not been met. Specifically, services were provided by an out-of-network provider. The Plan has contracted providers available to provide these 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 a comprehensive oral evaluation (D0150), bitewing radiographic images (D0274), intraoral periapical radiographic images (D0220, D0230 x2), and a filling (D2393) provided from January 9, 2021, through January 13, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room services on November 27, 2020.

You asked the Plan to waive the copayment for the emergency room services. You say that you still had the same issues at your physician office the next day. The Plan denied your request. The Plan says you were charged this copayment 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 $90 copayment for Emergency Care. 

You have been asked to pay a $90 copayment for the emergency room services. The emergency room services fall 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 the emergency room services on November 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz FX.

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 step therapy requirement is not met.

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has left knee osteoarthritis. She has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do not show that the required drugs are contraindicated or less effective; therefore, Supartz FX 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz FX.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair repair services.

You asked the Plan to pre-approve wheelchair repair services. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for repair services have not been met.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 

The file shows that the enrollee has another wheelchair from a different DME provider. The other wheelchair serves the same purpose as the wheelchair for which you have requested repair services. Therefore, we decided that the Plan does not have to pre-approve wheelchair repair services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the comprehensive oral evaluation (D0150), bitewings - four radiographic images (D0274), panoramic radiographic image (D0330), prophylaxis - adult (D1110) and topical application of fluoride - excluding varnish (D1208) provided December 29, 2020.

You asked the Plan to provide additional payment for the dental exam, bitewing x-rays, panoramic x-rays, dental cleaning, and fluoride treatment. You say that you made an appointment with a network dentist and the office rescheduled your appointment with another dentist who you assumed would also be a part of the dental network. The Plan denied your request. The Plan says the services were not provided by a network provider and therefore you are responsible for the costs about the Plan's allowed amount.

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 the dental exam, bitewing x-rays, panoramic x-rays, dental cleaning and fluoride treatment up to the Plan's maximum allowable benefit amount per service and up to $240 total for preventative services per calendar year. 

We looked at the file and Medicare rules. In this case you received services from a dentist who is not part of the Plan's third-party dental vendor's network. Based on this information, we decided that the Plan does not have to provide additional payment for the comprehensive oral evaluation (D0150), bitewings - four radiographic images (D0274), panoramic radiographic image (D0330), prophylaxis - adult (D1110) and topical application of fluoride - excluding varnish (D1208) provided December 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wellness visit, and lab services provided on January 8, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the OON services. You say that the services were provided due to the enrollee's condition and the pandemic. The Plan denied your request. The Plan says 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. 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 the wellness visit, and lab services provided on January 8, 2021 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that this necessary for you to return to being independent and active. The Plan denied your request. The Plan says you can be treated 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. Our physician reviewer found you were admitted for abdominal pain and had surgery to remove part of the colon. Your medical problems are now stable. There are no complex nursing or rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary services can be provided in a different level of 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for pulmonary function testing and a
pulmonology office visit provided on December 15, 2020.

You asked the Plan to waive the copayments for pulmonary function testing and specialist visit. You say that
you should not receive this bill during the COVID-19 waiver. The Plan denied your request. The Plan says the
copayment amounts you are being charged are correct.

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 $15
copayment for pulmonary function test and $40 copayment for specialist visit. Your total copayment obligation
is therefore $55.

You have been asked to pay $15 copayment for pulmonary function test and $40 copayment for specialist visit.
Pulmonary function testing and specialist visit fall within the "Outpatient Diagnostic Tests and Therapeutic
Services and Supplies" and "Physician/Practitioner Services, Including Doctor's Office Visits" benefit
categories. This means that you have been asked to pay the correct amount based on your contract with the
Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore,
we decided that the Plan does not have to waive the copayments for pulmonary function testing and a
pulmonology office visit provided on December 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a periodic oral evaluation, and teeth cleaning.

You asked the Plan to pre-approve a periodic oral evaluation, and teeth cleaning. You say that you have been
seeing this provider for years and you would like to continue to see this provider. The Plan denied your request.
The Plan says The Plan says you are not covered for these services when seen by an out-of-network provider.

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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of a periodic oral evaluation, and teeth cleaning have not been met. Specifically, the request is for
services to be provided out of network. The Plan has network providers available to provide the services at
issue. We found no exception that would require the Plan to pre-approve out of network services. Therefore,
we decided that the Plan does not have to pre-approve a periodic oral evaluation, and teeth cleaning.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental crown (D6058), abutment (D6057), surgical placement (D6010) and bone graft (D6104)

You asked the Plan to pre-approve dental services. You say that you are appealing this denial. The Plan denied your request. The Plan says these services are not covered by the Plan's dental 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. Therefore, we decided that the Plan does not have to pre-approve dental crown (D6058), abutment (D6057), surgical placement (D6010) and bone graft (D6104)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on April 1, 2020 by an out of network (OON) provider.

You asked the Plan to pay for genetic testing. You say that your lab performed all the tests that were ordered by the referring physician. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 genetic testing provided on April 1, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient psychiatric hospital services provided from February 9, 2020, to February 10, 2020.

You asked the Plan to pay for inpatient psychiatric hospital services after February 8, 2020. You say that you did not know the enrollee had a health Plan and needed authorization. The Plan denied your request. The Plan says inpatient psychiatric treatment was not medically necessary as of February 9, 2020.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.

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 inpatient psychiatric hospital services after February 8, 2020. Our reviewer says that the service was not medically necessary. Our physician reviewer found this enrollee did not appear to require inpatient mental health treatment beyond the date in question as she was not a danger to herself or others and did not have any auditory or visual hallucinations while being cooperative with treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis beyond the date in question. I am unable to find an individualized treatment plan however the entire chart is not present. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided for the admission of this patient does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of February 9, 2021 forward as this patient was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment while not showing any threats the safety.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services after February 8, 2020 have not been met. Therefore, we decided that the Plan does not have to pay for inpatient psychiatric hospital services provided from February 9, 2020, to February 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a frenulectomy (D7960), gingivectomy (D4212) and pulp cap (D3120) provided on May 12, 2020 to August 4, 2020.

You asked the Plan to pay for the dental services. You say that these services were necessary and benefit your overall health. The Plan denied your request. The Plan has agreed to cover the crowns and filling, however these other services are not covered by Medicare or by the Plan's supplemental dental benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a frenulectomy (D7960), gingivectomy (D4212) and pulp cap (D3120) provided on May 12, 2020 to August 4, 2020.