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

We decided that the Plan does not have to pay for an office visit (99204) provided on February 17, 2021, by an out of network (OON) provider.

You asked the Plan to pay for an office visit. You say that it was your understanding that the provider was contracted with the Plan. The Plan denied your request. The Plan says services were provided by an out-of-network provider without prior authorization. The Plan also says the provider should have verified the member's eligibility and health benefits prior to the visit.

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. The records provided for review do not show that the services at issue were urgent or emergent. 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 an office visit (99204) provided on February 17, 2021, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve Intensity Modulated Radiation Therapy (IMRT).

You asked the Plan to pre-approve Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; complex (77386), Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications (77301), Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan (77338), Therapeutic radiology simulation-aided field setting; simple (77280). You say that the enrollee needs IMRT. The Plan denied your request. The Plan says that the treatment plan and the use of chemotherapy are not clearly documented.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; complex (77386), Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications (77301), Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan (77338), Therapeutic radiology simulation-aided field setting; simple (77280). Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found per the LCD IMRT is approved for thoracic malignancy. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; complex (77386), Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications (77301), Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan (77338), Therapeutic radiology simulation-aided field setting; simple (77280) have been met. Therefore, we decided that the Plan has to pre-approve Intensity Modulated Radiation Therapy (IMRT).

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve suction-assisted lipectomy.

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 surgical treatment of gender dysphoria is covered when specific criteria are met. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found you are requesting suction-assisted lipectomy of the trunk for a diagnosis of gender dysphoria. This procedure is non-covered by Medicare for this indication. The services are not medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve suction-assisted lipectomy.
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 at this time you need total care. The Plan denied your request. The Plan says that you are receiving appropriate in-patient acute care and do not require transfer to LTACH.

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. You appear to be more stable and improving, requiring only short-term additional acute care services which can be safely be received at the current acute care facility until appropriate for a lower level of care. You do not require services at the LTACH that are not already available at the current facility. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH. 

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight pharmacogenomics testing provided on January 26, 2021.

You asked the Plan to pay for the testing services. You say that the test informs clinicians about which medications may have increased risk of side effects. The Plan denied your request. The Plan says the testing services are not covered.

The Plan must follow Medicare rules. Medicare rules say that pharmacogenomics testing is only covered under certain medical indications. 

We looked at the file and Medicare rules. The selection of the medications in question must be derived from clinical factors/necessity rather than from a PGx test. In this case, there are insufficient medical records to show that the testing guidelines have been met. 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 GeneSight pharmacogenomics testing provided on January 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 13, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that you were inadvertently billed incorrectly. You say you would like the charge paid by insurance. The Plan denied your request. The Plan says the provider is out-of-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 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. The record shows this provider's contract with the Plan termed on October 31, 2020. Therefore, we decided that the Plan does not have to pay for the office visit provided on January 13, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) and a prolonged service in an outpatient setting requiring direct patient contact beyond the time of the usual service; first hour (99354) rendered by the out of network (OON) provider on December 3, 2020 and December 21, 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 (99214) and a prolonged service in an outpatient setting requiring direct patient contact beyond the time of the usual service; first hour (99354) rendered by the out of network (OON) provider on December 3, 2020 and December 21, 2020.

Your complaint that you were advised by a Plan representative that this provider was participating within the Plan's network of providers is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Pneumococcal vaccine and administration provided on December 8, 2020 by an OON provider.

You asked the Plan to pay for the Pneumococcal vaccine and administration. You say that these 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. 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 Pneumococcal vaccine and administration provided on December 8, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services provided on January 20, 2020 by an out
of network (OON) provider.

You asked the Plan to pay for pathology services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan 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 pathology services provided on January 20, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tecentriq and Zirabev.

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. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 hepatocellular cancer. He is pre-treated with lenvatanib, sorafenib, and Keytruda. Tecentriq and Zirabev is only a first line regimen and is therefore not reasonable or medically necessary and safe and effective for the enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Tecentriq and Zirabev.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on February 10, 2021.

You asked the Plan to pay for the ambulance services. You say that you did not request for this service. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on February 10, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on February 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MyoPro Motion G Orthotic device.

You asked the Plan to pre-approve MyoPro Motion G Orthotic device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested device 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 MyoPro Motion G Orthotic device. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee had a stroke in 2009 and has right hemiparesis. The MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this enrollee, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities. Therefore, the enrollee does not meet criteria for the requested 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 MyoPro Motion G Orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve MyoPro Motion G Orthotic device.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to reimburse you for the 3 surgical extractions (D7210), the extraction of residual tooth roots (D7250), and the periapical x-ray (D0220) provided from January 9, 2020, to October 8, 2020.

You asked the Plan to reimburse you for the dental services. You say that based on the Evidence of Coverage, the plan pays 80% for the extraction of each tooth, regardless of the provider's network status. You also say that you should be reimbursed for these services. The Plan denied your request. The Plan says that the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made to providers who have opted out of Medicare.

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 the dental services have been met. Specifically, there is nothing in the Evidence of Coverage under Dental Services that explains that the services must be performed by a provider who has not opted out of Medicare. Therefore, we decided that the Plan has to reimburse you for the 3 surgical extractions (D7210), the extraction of residual tooth roots (D7250), and the periapical x-ray (D0220) provided from January 9, 2020, to October 8, 2020. 

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the services the enrollee requires do not require daily inpatient skilled nursing and/or therapy services.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 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-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmic diagnostic imaging (92133) provided on January 22, 2021.

You asked the Plan to waive the copayment for the eye exam. You say that this exam was a glaucoma screening and should have a $0 copayment. The Plan denied your request. The Plan says this claim was not filed as a glaucoma screening and this copayment was applied 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 $30 copayment for each specialist visit for a Medicare-covered eye exam for diagnosis and treatment of diseases and conditions of the eye. 

You have been asked to pay a $30 copayment for the eye exam. You say that this exam was a glaucoma screening, but the specific procedure code that was billed to the Plan (92133) is not a code for a glaucoma screening. In addition, a screening is typically provided when there are no symptoms or causes for concern. If a test is performed to investigate a symptom or issue, it is considered diagnostic and not a screening. Therefore, the eye exam you received is considered Medicare-covered eye exam for a diagnosis and treatment of diseases and conditions of the eye. 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 ophthalmic diagnostic imaging (92133) provided on January 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a teeth cleaning (D1110), and bitewing radiographic images (D0274) provided on November 3, 2020.

You asked the Plan to pay for a comprehensive oral evaluation, a teeth cleaning, and bitewing radiographic images. You say that you were not aware that the provider had opted out of Medicare.

The Plan denied your request. The Plan says you are responsible for services provided by privately contracted providers. The Plan will not reimburse for charges incurred by Medicare Opt Out providers.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation, a teeth cleaning, and bitewing radiographic images have not been met. Specifically, services were provided by an Opt Out provider. The Plan does not cover dental services when provided by an Opt Out provider. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a teeth cleaning (D1110), and bitewing radiographic images (D0274) provided on November 3, 2020.