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

We decided that the Plan does not have to waive the copayment for a specialist visit provided on December 18, 2019.You asked the Plan to waive the copayment for a specialist visit. You say that you were told that the visit would be processed as a primary care visit.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 specialist visits. You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for a specialist visit provided on December 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings provided on November 22, 2019.You asked the Plan to pay for the bitewings. You say that the Plan and dental office told you the bitewings would be covered.The Plan denied your request. The Plan says bitewing x-rays are payable once in any period of 12 consecutive months. The Plan also says that you were not eligible for additional bitewing x-rays.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, bitewing x-rays are limited to every 12 months. The record shows that you received bitewing x-rays on December 10, 2018 and your bitewings benefit had been exhausted.Therefore, we decided that the Plan does not have to pay for the bitewings provided on November 22, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ALS emergency ambulance service provided October 24, 2019.You asked the Plan to pay for the ambulance service. You say that you are requesting reconsideration of the denial as the plan had approved your rehabilitation at this rehabilitation center after having an aortic valve replacement surgery.The Plan denied your request. The Plan says the ambulance service (A0427) does not meet requirements for approval. Records show that the appropriate code is A0998 for ambulance response and treatment as the enrollee refused transport.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  The rules say that Medicare does not pay for ambulance services when there is no transport.In this case, the CPT Code Manual definition of code A0427 is ALS emergency ambulance services.We find that CPT code A0427 is not supported in the medical record. The ambulance company did not provide transport services on October 24, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Based on this information, we decided that Medicare rules for coverage of the ambulance service have not been met.Therefore, we decided that the Plan does not have to pay for the ALS emergency ambulance service provided October 24, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiation therapy services provided on March 12, 2019 to March 15, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the radiation therapy services. 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 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 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 the radiation therapy services provided on March 12, 2019 to March 15, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for occlusal guard/dental night guard (D9940) provided December 19, 2019.You asked the Plan to pay for the occlusal guard. You say that this was medically necessary because you have bruxism and you were advised by a plan representative that you could possibly be reimbursed.The Plan denied your request. The Plan says this service is not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for occlusal guard/dental night guard (D9940) provided December 19, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for CT guidance (77014) provided on October 30, 2019.
You asked the Plan to pay for the CT guidance. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the charges for these services should be included in the charge associated with CPT code 77301, even if the individual services associated with IMRT planning are performed on dates of service other than the date on which CPT code 77301 is reported. The Plan must follow Medicare rules. Medicare rules say that payment for CPT code 77014 is included in the APC payment for CPT code 77301 (IMRT planning). We find that CPT code 77014 is not supported in the record. Specifically, payment for 77014 is included in the APC payment for CPT code 77301. Based on this information, we decided that Medicare rules for coverage of the CT guidance have not been met. Therefore, we decided that the Plan does not have to pay for CT guidance (77014) provided on October 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction of peripheral nerve or branch/injection treatment of nerve (64640).You asked the Plan to pre-approve destruction of peripheral nerve or branch/injection treatment of nerve. You say that the service is necessary due to the severe pain you are experiencing.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 destruction of peripheral nerve or branch/injection treatment of nerve. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/ investigational procedure that is the subject of ongoing clinical trials. You are not enrolled in a clinical trial. Therefore, the request is deemed not medically reasonable or 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 destruction of peripheral nerve or branch/injection treatment of nerve have not been met.Therefore, we decided that the Plan does not have to pre-approve destruction of peripheral nerve or branch/injection treatment of nerve (64640).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the placement of breast localization device provided on December 12, 2019.You asked the Plan to waive the copayment for the placement of breast localization device. You say that you disagree with the charges because this procedure was necessary for another procedure.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 toits 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 $225 copayment for outpatient surgery services provided in an outpatient hospital facility. You have been asked to pay a $225 copayment for the placement of breast localization device. The placement of breast localization device falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore,we decided that the Plan does not have to waive the copayment for the placement of breast localization device provided on December 12, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the injections rendered to you on November 7, 2019.
You asked the Plan to waive the coinsurance for these services. You say that you shouldn't have any member responsibility. The Plan denied your request. The Plan says the coinsurance 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 20% of the total cost for other Part B drugs.
Review of the file shows that you received an injection of infliximab and infusion of saline solution on November 7, 2019. You have been asked to pay 20% of the total cost for these services, for a total of $314.70. These services fall within the other Part B drugs 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 for the injections rendered to you on November 7, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous radiofrequency ablation (RFA) therapy.
You asked the Plan to pre-approve endovenous RFA therapy. You say that the enrollee has worn compression stockings, attempted leg elevation, and taken anti-inflammatory drugs for over 3 months with minimal relief of symptoms. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the records do not show that the enrollee has had a 3-month trial of conservative therapy including weight reduction.
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 endovenous RFA therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found to be reasonable and medically necessary, the enrollee has to have lifestyle limiting symptoms attributable to venous insufficiency in the absence of significant peripheral artery disease. The enrollee has numerous cardiovascular risk factors and a history of circulation problems. There is no satisfactory assessment of lower extremity arterial perfusion documented in the materials provided. The enrollee has a history of obesity and is a current smoker with chest pain. The degree of reflux in the great saphenous vein (GSV) is not severe. There is no documentation that the enrollee is having lifestyle limiting lower extremity symptoms. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of endovenous RFA therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve endovenous radiofrequency ablation (RFA) therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 6, 2019 by an out of network (OON) provider.You asked the Plan to pay for these services. You say that this visit was medically necessary.The Plan denied your request. The Plan says that there is no network deficiency.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 the medical services provided on February 6, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation and periapical x-rays rendered on November 5, 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 covered.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay for the limited oral evaluation and periapical x-rays rendered on November 5, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for basic support routine disposable supplies (A0382) provided July 4, 2019.You asked the Plan to pay for basic support routine disposable supplies. You say that you are requesting reconsideration of the denied charges. The emergency room doctor said the enrollee could not be treated at the original hospital and ordered ambulance transfer to another hospital.The Plan denied your request. The Plan says payment for these items is included in the transportation fee. Medicare does not allow for separate billing of these services and supplies.The Plan must follow Medicare rules. Medicare rules say that payment for this service is included in the transportation fee.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of basic support routine disposable supplies have not been met.Therefore, we decided that the Plan does not have to pay for basic support routine disposable supplies (A0382) provided July 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture provided by an out-ofnetwork
dentist on January 14, 2020.
You asked the Plan to pay for the complete maxillary denture. You say that this was the only provider you
could find that would accept your x-rays and was not as costly as the other providers. The Plan denied your
request. The Plan says non-emergency services provided by an out-of-network provider are not available with
your dental plan.
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
covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for
the complete maxillary denture provided by an out-of-network dentist on January 14, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tbo-filgrastim (Granix) for the enrollee.
You asked the Plan to pre-approve Granix. You say that growth factors support using Granix The Plan denied
your request. The Plan says the enrollee has not had previous treatment, or an intolerance to Neupogen and
Nivestym.
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 Granix. Our physician reviewer found
that the enrollee has Small cell carcinoma of the right lung, with Agranulocytosis secondary to cancer
chemotherapy. The Plan requires a trial of Neupogen and/or Nivestym before they will approve the requested
drug. The documentation does not show the enrollee has tried and failed the required drugs. The documentation
does not support that Neupogen (Filgrastim) or Nivestym (Filgrastim-aafi) would likely be less effective,
and/or would likely have adverse effects for the enrollee in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Granix have not been met. Therefore, we decided that the Plan does not have to
pre-approve tbo-filgrastim (Granix) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found this enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The skilled nursing or skilled therapy services (or a combination of these services) are not needed on a "daily basis" in a SNF. As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on August 9, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you were told that you had no charge. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there are in-network providers available for these 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 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 physician services provided on August 9, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric services.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on February 19, 2020 with severe depressed bipolar disorder, post-traumatic stress disorder, attention deficit hyperactivity disorder, and borderline personality disorder. Based on the submitted records, it is not expected the enrollee will improve in a reasonable period of time, as she does not have dangerousness to self or others and is not showing any delusions or hallucinations. She is cooperative with care and is not showing aggressive behaviors. It does not appear that active treatment is taking place or that the services are necessary to improve the enrollee's condition or for the purpose of diagnosis. The inpatient services are not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric services