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

We decided that the Plan does not have to pay for oral exam (D0450) full panoramic x-ray (D0330) complete upper denture (D5110) provided by an out-network-provider on October 30, 2019.You asked the Plan to pay forthe dental services. You say that codes D0150, D0330 and D5110 are listed as being covered procedures. You are well within the allowed coverage with $590 left if paid in full. If you are allowed $2,000 per year then why can't you use it.The Plan denied your request. The Plan says this claim was processed correctly and the maximum allowable fee was paid. You are responsible for any difference between the maximum allowable fee and the amount the provider bills for the services.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 the difference between the maximum allowable fee and the amount the provider bills for their services when you receive services from an out-of-network dental provider.  You have been asked to pay $611 for the dental services. The services fall within the Dental services 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 pay fororal exam (D0450) full panoramic x-ray (D0330) complete upper denture (D5110) provided by an out-network-provider on October 30, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) for lung
cancer screening.
You asked the Plan to pre-approve a LDCT for lung cancer screening. You say that the service is necessary.
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not
been met.
The Plan follows Medicare rules. Medicare rules say that lung cancer screening with LDCT is covered when
specific criteria is 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 pre-approve a LDCT for lung cancer screening. Our
reviewer says that the services are not medically necessary. Our physician reviewer found review of an office
note dated March 16, 2020 does not clearly discuss the enrollee's tobacco use history. Without this, medical
necessity cannot be determined.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a LDCT for lung cancer screening have not been met. Therefore, we decided
that the Plan does not have to pre-approve a low dose computed tomography (LDCT) for lung cancer
screening.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea complete upper denture (D5110) and partial lower denture (D5214).You asked the Plan to pre-approvea complete upper denture and partial lower denture. You say that your current dentures were not made correctly. The office that made them advised you they would correct the issue, however you have not received any response from them and you are in need of your dentures.The Plan denied your request. The Plan says the requested services are not coveredbenefits.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-approvea complete upper denture (D5110) and partial lower denture (D5214).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNFservices to be provided by requested provider.You asked the Plan to pre-approve the SNF services. You say that your doctor ordered you to go to a skilled nursing facility to have physical therapy services. The Plan denied your request. The Plan says there are in-network facilities available that can provide the same services.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 requested 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. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve SNF services to be provided by requested provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve nephrology visit. You say that you would prefer to follow-up with the provider that did your surgery.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network nephrologist.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 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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services for the enrollee.You asked the Plan to pre-approveSNF services. You say that the enrollee needs additional therapy.The Plan denied your request. The Plan says that the enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for continued SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthyroid cancer gene expression analysis provided on September 25, 2019.You asked the Plan to waive the coinsurance forthyroid cancer gene expression analysis. You say that you 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 20% coinsurance for molecular and predisposed genetic testing. You received thyroid cancer gene expression analysis on September 25, 2019. The allowed amount is $3,200 and 20% of that is $640.You have been asked to pay the total coinsurance amount of $640 for thyroid cancer gene expression analysis. Thyroid cancer gene expression analysis falls within the outpatient diagnostic tests and therapeutic services and supplies 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 forthyroid cancer gene expression analysis provided on September 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide acupuncture.
You asked the Plan to provide acupuncture. You say that you have weakness in your back and you do not want to take any pills. The Plan denied your request. The Plan says acupuncture is not covered under any circumstance.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90 period, and no more than 20 sessions per year. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, Your EOC clearly states that acupuncture is not covered under any condition. Therefore, we decided that the Plan does not have to provide acupuncture.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea computed tomography (CT) scan of the abdomen/pelvis for enrollee.You asked the Plan to pre-approvethese 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 CT scans 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 has recently-diagnosed prostate cancer based on one positive core with a Gleason score of 6. There is no documentation ofsevere symptoms or pain. A CT scan for the purpose of screening is not currently medically necessary or reasonable.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverageof these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea computed tomography (CT) scan of the abdomen/pelvis for enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 9, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care or if the care cannot be provided with an in-network provider, which requires prior authorization from 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 requested provider in this case is not a network provider with the Plan. 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's services provided on October 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe endostealimplant (D6010) provided on October 14, 2019.You asked the Plan to pay forthe dental service. You say that insurance should not be deciding what dental services are covered. You also say that your dental insurance is of no use.The Plan denied your request. The Plan says implants are not a covered service. The Plan says they contacted the provider and confirmed that implants are covered by your primary insurance but your dental benefit had been maxed out. The Plan also says that your treatment plan was based on the benefits from your primary insurance.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 implant is not among those covered under your secondary plan.Therefore, we decided that the Plan does not have to pay forthe endosteal implant (D6010) provided on October 14, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray provided on December 2, 2019.You asked the Plan to waive the copayment forthe x-ray. You say that you should not be responsible for the copayment.The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $40 copayment for each basic imaging service (e.g., general x-rays or ultrasound). For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $40 copayment for x-ray.You have been asked to pay a $35.90 copayment for the x-ray. The x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 forthe x-ray provided on December 2, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the vision services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe vision services. You say that your vision is getting worse.The Plan denied your request. The Plan says that you must receive your care from a network 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 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 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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvethe vision 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 pre-approvea neurology consultation to be provided by the Dr. at Out Of Network Provider.You asked the Plan to pre-approveneurology consultation. You say that the recommended in-network neurologist does not work with patients with your condition.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-networkneurologist.Medicare rules generally allow plans to restrict enrollees to using plan providers as long asthere are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you 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 neurology consultation. Our reviewer says that you do not meet the Medicare criteria for out-of-network treatment with the Dr. Our physician reviewer found the Plan's denial is medically justified on the basis that it is offering adequate care to meet your needs through referral to in-network providers the doctors. There is not anything unique about your condition that would make it medically necessary for you to see the requested out-of-network neurologist. The Plan has shown that they have in-network providers who meet the Standards of Care required for treatment of your 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 out-of-network neurology consultation have not been met.Therefore, we decided that the Plan does not have to pre-approvea neurology consultation to be provided by the doctor at Out Of Network Provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care rendered to enrollee from June 17, 2019 to June 18, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not separately payable.The Plan must follow Medicare rules. The rules say that follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery are included in the global surgical package.We looked at the file and Medicare rules. The provider submitted a claim for procedure code 99232 (subsequent hospital care). These services were rendered within 90 days of a major surgical procedure billed with code 27245. Payment for these services is included in the global surgical package.Therefore, we decided that the Plan does not have to pay for the subsequent hospital care rendered to enrollee from June 17, 2019 to June 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical equipment to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the light weight wheelchair. You say that you would like reconsideration because the DME options for this member are limited. The Plan denied your request. The Plan says this equipment is available in-network.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 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical equipment 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 fordiagnostic or therapeutic agent injections (64490, 64491 and 64492) provided on October 16, 2019.You asked the Plan to pay forthe injections. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the submitted record does not support the services billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 64490 is injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level.The CPT code Manual definition of code 64491 is injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level (List separately in addition to code for primary procedure).The CPT code Manual definition of code 64492 is injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure). We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correctin denying the request to pay for the injections. Our reviewer says that CPT codes 64490, 64491 and 64492 do not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records submitted do in include a written narrative description of the procedures including an injection technique and where the needle was placed anatomically.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injections have not been met.Therefore, we decided that the Plan does not have to pay fordiagnostic or therapeutic agent injections (64490, 64491 and 64492) provided on October 16, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean iStent eye procedure.You asked the Plan to pre-approvethe procedure. The Plan denied your request. The Plan says this 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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the use of iStent implantation in thiscase is not likely more beneficial than any other standard therapy. The enrollee had visually significant cataract causing night vision difficulty, and mild glaucoma but has never been on medical therapy. The use of iStent is approved by the FDA for use to treat the enrollee's glaucoma in the setting of treatment with 1 to 2 topical medications. There is no evidence in the medical literature that suggests iStent is safe and effective for first-line treatment of glaucoma. The trials and studies to date involve patients already treated with topical medication. The standard therapy of cataract surgery alone with or without topical glaucoma afterward, would be the standard of care for this 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 the procedure have not been met.Therefore, we decided that the Plan does not have to pre-approvean iStent eye procedure.