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

We decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe
gingival inflammation (D4346) received November 5, 2020, from the out-of-network provider.
You asked the Plan to pay for the dental service. You say that the enrollee was never informed that this would
be an out-of-pocket expense. The Plan denied your request. The Plan says based on the enrollee's contract with
the Plan, the enrollee is responsible for 100% of the cost for scaling services when they are received out-ofnetwork.
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 only
covered under this benefit when received from an in-network provider. If the enrollee receives these services
out-of-network then they are responsible for 100% of the cost. Therefore, we decided that the Plan does not
have to pay for the scaling in presence of generalized moderate or severe gingival inflammation (D4346)
received November 5, 2020, from the out-of-network provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on January 11, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the physician services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The 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 the physician services provided on January 11, 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 long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the requested admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to an LTACH is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the current facility. The enrollee does not require services at the LTACH that are not available at the current facility. There are no services available at the LTACH that the enrollee requires that are not available at the current facility. Transfer to a lower level of care may be considered when treatment has completed and the enrollee is more stable. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99215), electrocardiogram (93000), advance care planning (99497), and the extracranial bilateral study (93880) rendered by the out of network (OON) provider on October 14, 2020.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without 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 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 office visit (99215), electrocardiogram (93000), advance care planning (99497), and the extracranial bilateral study (93880) rendered by the out of network (OON) provider on October 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services provided on February 15, 2021.

You asked the Plan to pay for the services provided. You say that the test is deemed medically necessary. The
Plan denied your request. The Plan says the claim processed correctly.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.

We looked at the file and the rules. The records show that molecular testing was provided. The testing was
billed along with diagnosis codes for malignant neoplasm of the right lung, and for an unspecified part of an
unspecified lung. Since the right side of the lung has been documented, it is not appropriate to also report an
unspecified side. 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 testing services provided on February 15,
2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-emergency ground ambulance transportation.

You asked the Plan to pre-approve non-emergency ground ambulance transportation. You say that it is medically necessary for the enrollee to receive ambulance transportation to dialysis appointments. The Plan denied your request. The Plan says there is no medical need for non-emergency ambulance transportation.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

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 non-emergency ground ambulance transportation. Our reviewer says that the requested non-emergency transportation services are not medically necessary for the enrollee's condition. Our physician reviewer found the enrollee is an 80-year-old female with end stage renal disease on hemodialysis requesting ambulance transport to and from hemodialysis. The review has determined that the documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) would be contraindicated for this patient. The does not documentation support that the patient needs the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. The documentation does not support that the ambulance transport would be medically reasonable and necessary for the patient. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of non-emergency ground ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve non-emergency ground ambulance transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the advanced care planning services represented by code 99497 provided on March 8, 2021.

You asked the Plan to pay for code 99497. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of code 99497.

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 99497 is Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate.

We find that code 99497 is not supported in the medical record. Specifically, code 99497 is a time-based code. In order to bill code 99497, the documentation must note that the first 30 minutes were face-to-face with the patient, family member(s), and/or surrogate for advance care planning. The records do not document this. Based on this information, we decided that Medicare rules for coverage of code 99497 have not been met. Therefore, we decided that the Plan does not have to pay for the advanced care planning services represented by code 99497 provided on March 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (99308) provided on
December 3, 2020 by an out of network (OON) provider.

You asked the Plan to pay for subsequent nursing facility care. You say that the enrollee is a resident of a
nursing home and was seen by the nurse practitioner for medically necessary reasons. You are appealing based
on medical necessity. The Plan denied your request. The Plan says enrollee's must receive their medical
services from an in-network provider with the exception being urgent or emergent services. Non-emergent
services with non-contracted providers require prior authorization before services being rendered.

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 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 subsequent nursing facility care (99308) provided on December 3, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor supplies provided on January 27, 2021.

You asked the Plan to pay for the therapeutic continuous glucose monitor supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the items billed are not supported by the documentation.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain a proof of delivery or relevant medical records which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. There is no documentation indicating that the provider discussed the need for the billed supply code. Therefore, we decided that the Plan does not have to pay for the therapeutic continuous glucose monitor supplies provided on January 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic facet joint injection.

You asked the Plan to pre-approve a therapeutic facet joint injection. You say that this request is medically necessary. The Plan denied your request. The Plan says the previous therapeutic injection failed to help with pain relief.

The Plan follows Medicare rules. Medicare rules say that the previous injection must have resulted in at least 50% pain relief for at least three (3) months or at least 50% consistent improvement in the ability to perform previously painful movements and activities of daily living. 

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 therapeutic facet joint injection. Our reviewer says that the request is not medically reasonable and necessary. Our physician reviewer found that the enrollee is a 97-year-old female with a history of chronic mid-back pain affecting daily life. She has previously undergone a facet joint injection at T10-T11 using local anesthetic and steroid on April 6, 2021. The medical records indicate that the injection did not help her, and initially it made her pain worse. The member's provider has recommended another facet injection. In this case, the documentation indicates that the previous facet injection performed April 6, 2021, did not help her at all, and initially possibly made her pain worse. The review has determined that the medical documentation does not support that the criteria have been met for the requested injection.

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 therapeutic facet joint injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic facet joint injection.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home health aide.

You asked the Plan to pre-approve home health aide. You say that you cannot walk well and could fall. The Plan denied your request. The Plan says the denial of authorization for home health aide services is correct.

The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 

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 home health aide. Our reviewer says that you do not meet the Medicare criteria for a home health aide. Our physician reviewer found you are not receiving any skilled home health care. There is no documentation that home health aide services are reasonable and necessary to the treatment of your illness or injury by skilled professional staff.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health aide have not been met. Therefore, we decided that the Plan does not have to pre-approve a home health aide.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Life2000 Ventilation System (E0466).

You asked the Plan to pre-approve a Life2000 Ventilation System. You say that the requested item is a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules for the requested item have not
been met.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.

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 Life2000 Ventilation System. Our
reviewer says that the requested item is not medically necessary at this time. Our physician reviewer found that
the Life2000 Ventilation System at issue is not a true ventilator. There is inadequate evidence that this device is
beneficial in chronic obstructive pulmonary disease (COPD). There is no order for a home ventilator, but
medical necessity for that device has not been established. The enrollee has COPD but there is no
documentation of carbon dioxide (CO2) retention on an arterial blood gas (ABG) test, and failure of bi-level
positive airway pressure (BiPAP) has not been demonstrated.

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 Life2000 Ventilation System have not been met. Therefore, we decided that
the Plan does not have to pre-approve a Life2000 Ventilation System (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve palliative IMRT.

You asked the Plan to pre-approve palliative IMRT. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for IMRT have not been met because the requested treatment is not medically reasonable and 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 palliative IMRT. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation for why IMRT is needed. While a comparative plan is shown, there is no documentation that the non-IMRT plan would be unacceptable or that the IMRT plan would result in a clinically meaningful and plausible benefit. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of palliative IMRT have not been met. Therefore, we decided that the Plan does not have to pre-approve palliative IMRT.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus testing services provided on July 17, 2020.

You asked the Plan to pay for the testing services. You say that the test was ordered to determine the best course of treatment for the enrollee's specific cancer. The Plan denied your request. The Plan says the requested codes are being bundled into a larger primary panel 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. The file shows that payment for the testing panel using multiple procedure codes was requested. 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 Tempus testing services with multiple codes, provided on July 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $10 copayment charged for an office visit provided on
February 1, 2021.

You asked the Plan to waive this copayment. You say that this was an annual wellness visit and should be no
charge. The Plan denied your request. The Plan says this copayment was charged based on the claim submitted
by the provider and the Plan contract agreement. The Plan stated that any additional services billed beyond
those limited in the annual wellness visit will incur a copayment.

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 explains additional services provided
beyond those limited by the annual wellness visit will incur cost share. Your contract with the Plan says that
you must pay a $10 copayment for each physician visit. Based on the claim submitted by your provider,
additional services were provided beyond the scope of an annual wellness visit. 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 $10
copayment charged for an office visit provided on February 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Coflex procedure.

You asked the Plan to pre-approve the Coflex procedure. You say that the requested procedure is medically
necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is
considered experimental/investigational.

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 Coflex procedure. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found The Coflex device is experimental. More research is needed to show safety and
efficacy. High failure rates with similar devices have been reported.

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 Coflex procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve the Coflex procedure.