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

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on May 23, 2019.
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says that
the Plan requires utilization of network providers when possible and available, and requires authorization for
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency
situation, has been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for a domiciliary, rest home visit provided on May 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten removals of residual tooth roots and three extractions.
You asked the Plan to pre-approve the removals of residual tooth roots and extractions. You say that you cannot afford the surgical removals and your health is not the best. You also say that you would like your teeth fixed, but you cannot afford it. The Plan denied your request. The Plan says your extractions benefit has been exhausted.
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, extractions are limited to two procedures per calendar year. The record shows that you were approved for two removals of residual tooth roots on April 1, 2020, and your extractions benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve ten removals of residual tooth roots and three extractions.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa for the enrollee.
You asked the Plan to pre-approve Euflexxa. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that there is no documentation that Hyalgan, Hymovis or Synvisc was tried within last 365 days.
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 Euflexxa. Our reviewer says that Euflexxa is not medically reasonable and necessary for the enrollee in this case. The enrollee is noted to have osteoarthritis of both knees. The health plan requires that other forms of hyaluronic acid injections be used. There is no evidence that the enrollee is allergic to or intolerant of these other forms of hyaluronic acid. There is no evidence that the enrollee has tried and not responded to these other forms of hyaluronic acid injections. There is no documentation as to why these other forms of hyaluronic acid would not be expected to be safe and effective for the enrollee. Our physician reviewer found that the enrollee does not meet step therapy criteria for coverage of Euflexxa.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup, tooth 14 (D2950).
You asked the Plan to pre-approve the dental services. You say that you are recommending restoring decay
with a buildup and crown. The Plan denied your request. The Plan says this service is not covered under the
plan 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 core
buildup, tooth 14 (D2950).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing coded G0482 and 80307 provided on July 22, 2019.You asked the Plan to pay forthe drug testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.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 find that CPT codes G0482 and 80307 are not supported in the medical record. Specifically, the documentation does not support any evidence of an established relationship between the enrollee and the ordering physician. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met.Therefore, we decided that the Plan does not haveto pay forthe drug testing coded G0482 and 80307 provided on July 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the specialist office visits and the debridement services provided from February 18, 2020 to March 23, 2020.
You asked the Plan to waive the cost share for the specialist office visits and the debridement services. You say that you were under the impression that diabetes related problems were 100% covered. The Plan denied your request. The Plan says the cost share for the specialist office visits were reprocessed and 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. Your contract with the Plan says that there is a $750 deductible that applies towards additional services received during a specialist office visit and a $35 copayment for each specialist visit. The specialist office visits and the debridement services you asked the Plan to waive the cost share for fall within the "Physician/Practitioner services, including doctor's office visits" benefit category each specialist visit. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that applies towards additional services received during a specialist office visit and a $35 copayment for each specialist visit. The record shows that the debridement services are considered surgical physician services. See chart below. This cost sharing is a contractual obligation that had not been met at the time the specialist office visits and the debridement services were received on February 18, 2020 to March 23, 2020. Therefore, we decided that the Plan does not have to waive the cost share for the specialist office visits and the debridement services provided from February 18, 2020 to March 23, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued 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 for the enrollee. The Plan denied your request. The Plan says that the documentation fails to indicate that the member has any daily skilled needs that require physician oversight and at least one hour a day of daily skilled therapy.
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-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for CPT code 99204 provided on February 20, 2020.
You asked the Plan to pay for CPT code 99204. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered as 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 99204 is Office or other outpatient visit for the evaluation and management of a new patient. We find that CPT code 99204 is supported in the medical record. Specifically, the file shows CPT code 99204 was billed by a thoracic surgeon. The Plan denied payment for this service because a vascular surgeon saw the enrollee on a different date of service as part of the same group practice. Medicare allows for separate payment when services are provided by different specialties as in this case. Therefore, we decided that the Plan has to pay for CPT code 99204 provided on February 20, 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 pay for the skilled nursing services provided from October 29, 2019
to November 5, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the service
was not medically necessary.
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 pay for the skilled nursing services. Our reviewer
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 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 skilled nursing services have not been met. Therefore, we decided that the
Plan does not have to pay for the skilled nursing services provided from October 29, 2019 to November 5,
2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the DecisionDx-Melanoma testing provided on February 4, 2020.
You asked the Plan to pay for the testing services. You say that the results will provide risk-specific surveillance and management for the enrollee. The Plan denied your request.
The Plan follows Medicare rules. Medicare rules say that DecisionDx-Melanoma testing is only covered under certain medical indications. 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 the testing services. Our physician reviewer found that commercially available gene expression profiles (GEP) tests are marketed as being able to classify cutaneous melanoma into separate categories based on risk of metastasis. However, it remains unclear whether these tests provide clinically actionable prognostic information when used in addition to or in comparison with known clinicopathologic factors or multivariable nomograms that incorporate patient sex, age, tumor location and thickness, ulceration, mitotic rate, lymphovascular invasion, microsatellites, and SLNB status. Furthermore, the impact of these tests on treatment outcomes or follow-up schedules has not been established. This patient does not meet the criteria cited above, and there is no mention of using DecisionDx melanoma to determine eligibility for a clinical trial. Therefore, the service 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 the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the DecisionDx-Melanoma testing provided on February 4, 2020.
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 a skilled nursing facility does not offer the therapy you need. The Plan denied your request. The Plan says your needs could be met in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not require intensive physician or nursing monitoring in an IRF. You may benefit from physical and occupational therapy but the documentation does not indicate that your functional level requires an intensive therapy program in an IRF. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Life Alert (A9280).
You asked the Plan to pre-approve the Life Alert. You say that you need a life alert around your neck because you are overweight and scared that you might fall again because you constantly fall will be living alone and a Life Alert will make you feel safe. The Plan denied your request. The Plan says this item is not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the Life Alert (A9280).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from January 20, 2020 through January 23, 2020.
You asked the Plan to waive the copayment for the inpatient stay. You say that you are on an approved program that allows you to not pay for services. You say that you were not told there would be a bill. The Plan denied your request. The Plan says the copayment 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). The enrollee's contract with the Plan clearly says that enrollees must pay $230 per day for days 1-7 of a hospital stay. The enrollee has been asked to pay a $690 copayment for the inpatient stay. ($230/day x 3 days = $690). The inpatient stay falls within the "Inpatient mental health care" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient stay provided from January 20, 2020 through January 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete lower denture (D5120) and complete upper denture (D5110).
You asked the Plan to pre-approve the dental services. You say that your dentist sent in documents showing why this is necessary. You are hypoglycemic and currently on an all protein diet and you needs the dentures to be able to chew. The Plan denied your request. The Plan says this service is not covered under the plan 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 complete lower denture (D5120) and complete upper denture (D5110).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided from April 4, 2019 to June 19, 2019.
You asked the Plan to waive the copayments for outpatient rehabilitation services. You say that you cannot afford 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 a $40 copayment for outpatient rehabilitation services. You received outpatient rehabilitation services from April 4, 2019 to June 19, 2019 for a total of 11 visits. Therefore, you are responsible to pay a $40 copayment per each visit. The total amount you owe is: $40 (copayment) x 11 (outpatient rehabilitation services) = $440. You have been asked to pay the total copayment amount of $440 for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation 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 waive the copayments for outpatient rehabilitation services provided from April 4, 2019 to June 19, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvemyocardial perfusion imaging/SPECT scan for the enrollee.You asked the Planto pre-approvethe scan. You say that this is medically necessary.The Plandenied your request. The Plansaysthis imaging is not supported without the results of an ECG.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 the scan. Our reviewer says that the requested imaging is not medically reasonable or necessary. Our physician reviewer found based on the records, the enrollee has increased coronary risk but no documented cardiac symptoms or objective cardiac abnormalities. In this circumstance, preoperative screening stress testing has not been shown to improve cardiac outcome and is not recommended. Coverage criteria are not met since there is no documented covered indication for the procedure. 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 scan have not been met.Therefore, we decided that the Plandoes not haveto pre-approvemyocardial perfusion imaging/SPECT scan for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on February 5, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab services. You say that you would like this claim reprocessed and approved for payment. 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 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. 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 lab services provided on February 5, 2020 by an out of network (OON) provider.