Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87086, 81001) provided on March 11, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says services were provided 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 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 laboratory services (87086, 81001) provided on March 11, 2021, 
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 custom fabricated abutment (D6057), abutment supported retainer for porcelain fused to metal (D6069), and pontic (D6240) provided on February 8, 2021.
You asked the Plan to pay for the custom fabricated abutment, abutment supported retainer for porcelain fused to metal, and pontic. You say that the implants needed to be replaced and you thought these services would be processed under medical. The Plan denied your request. The Plan says your benefits do not include coverage for dental implants. The Plan also says that your $500 dental maximum has been met.
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, implant services are not among those covered under this benefit. The Plan offers a $500 combined preventive and comprehensive services allowance per calendar year. The record shows that you met the annual maximum benefit while processing this claim for the February 8, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the custom fabricated abutment (D6057), abutment supported retainer for porcelain fused to metal (D6069), and pontic (D6240) provided on February 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing provided on May 11, 2021.
You asked the Plan to pay for genetic testing. You say that this testing is designed to inform the enrollee and physician in advance of radiographic detection. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing did not meet Medicare coverage criteria.
The Plan follows Medicare rules. Medicare rules state that Guardant360 testing may be covered under certain specific circumstances.
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 genetic testing. Our reviewer says that this testing does not meet the Medicare criteria for coverage. Our physician reviewer found the enrollee was diagnosed with colon cancer after a mass was found in his colon during a colonoscopy. He had surgery to remove the cancerous tumor. Biopsies were performed on the tumor to confirm the diagnosis. There is no documentation submitted showing that there was not enough tumor tissue to have genetic testing completed. The documentation also indicates that the enrollee was not seeking further treatment for his cancer and chose to have cancer surveillance.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 testing provided on May 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair power seat elevation system.
You asked the Plan to pre-approve a power seat elevation feature (E2300). You say that you need a Group 3 power wheelchair, accessories and power seat elevation system. The Plan denied your request. The Plan says a seat elevator does not serve a primary medical purpose and is statutorily non-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 a power wheelchair power seat elevation system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultraviolet multidirectional light therapy system (E0694) to treat vitiligo.
You asked the Plan to pre-approve an ultraviolet light system. You say that the enrollee suffers from vitiligo on his face, underarms, and bilateral hands and it is recommended to start treatment with the home-based UV light device. The Plan denied your request. The Plan says this item is only covered for patients with generalized, intractable psoriasis.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. This item is only covered for patients with generalized, intractable psoriasis. The records show that you have vitiligo. You do not have a diagnosis of psoriasis. Based on this information, we decided that Medicare rules for coverage of an ultraviolet light system have not been met. Therefore, we decided that the Plan does not have to pre-approve an ultraviolet multidirectional light therapy system (E0694) to treat vitiligo.
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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 pay for the group therapy procedures provided on March 4, 2021, billed with code 97150-GP.
You asked the Plan to pay for the group therapy services. You say that this is correctly coded and should be paid. The Plan denied your request. The Plan says the Medicare criteria for these services are not met.
The Plan must follow Medicare rules. Medicare rules say that payment can only be made for therapy services provided by an NP when that provider is licensed to provide therapy by the State. Review of the file and publicly available records, we find that the physical therapy services at issue in this case were rendered by an NP who is not licensed to provide physical therapy in your state. Therefore, we decided that the Plan does not have to pay for the group therapy procedures provided on March 4, 2021, billed with code 97150-GP.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on March 16, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says due to the enrollee's hospice election at the time of service, this claim should be submitted to Original Medicare.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on March 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on April 1, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that your regular dentist initially told you that they could pull your tooth, but after examination they said they cannot pull it and referred you to an oral surgeon. You also say that you got an appointment with an oral surgeon 2 weeks later, but since your tooth was painful, you could not have waited for so long and found another dentist who agreed to examine the tooth and pull it. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit 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, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on March 29, 2021 and your problem focused limited oral evaluation (D0140) has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on April 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox.
You asked the Plan to pre-approve Botox. You say that a gastric pacemaker would be the only other solution to the problem. The Plan denied your request. The Plan says the clinical effectiveness of Botox for gastroparesis has not been demonstrated in peer-review literature.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Botox. Our physician reviewer found that no formal gastric emptying scan was provided to support the contention that the enrollee has gastroparesis. Although trials evaluating the effect of intrapyloric botulinum toxin injection on gastroparesis have been reported, there is no agreement whether botulinum toxin can effectively relieve the symptoms and improve the results of gastric emptying study in patients with gastroparesis. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital care, per day (99223) provided on
December 23, 2020.
You asked the Plan to pay for initial hospital care, per day (99223). The Plan denied your request. The Plan says there are missing patient medical records for this service.
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.
We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical documents to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of initial hospital care, per day (99223) have not been met. Therefore, we decided that the Plan does not have to pay for initial hospital care, per day (99223) provided on December 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal guard (D9944) provided on January 16, 2020.
You asked the Plan to pay for the occlusal guard. You say that you were told to request reimbursement from your plan. The Plan denied your request. The Plan says this service is not covered.
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 the occlusal guard (D9944) provided on January 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on
February 4, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request.
The Plan says the ambulance benefit is a transportation-based benefit, so if an ambulance supplier does not
transport the member, no service was provided.
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 4, 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 ambulance response and treatment, no transport
provided on February 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
You asked the Plan to pre-approve a portable oxygen concentrator. You say that when you go anywhere you need to make two trips to the car, which is not possible. The Plan denied your request. The Plan says your needs are met with your current standard oxygen concentrator and portable tanks.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The rules also say that if equipment serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Additionally, the records shows that this item would serve the same purpose as the portable oxygen tanks you are currently using. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on November 24, 2020.
You asked the Plan to pay for the eye refraction. You say that you do not recall the medical services the physician performed. The Plan denied your request. The Plan says an eye refraction is not a covered benefit.
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.
We looked at the file, the Medicare rules and the Plan's rules. The file shows that you received an eye refraction, which is not a covered benefit under Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on November 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested IRF care is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for IRF care have not been met because the requested level of care is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and does 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. The patient appears to be unstable with worsening kidney function requiring additional short term acute care services which can safely be received at the current acute care facility until more stable. The patient does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy (45385) provided on April 8, 2021.
You asked the Plan to waive the copayment for a colonoscopy. You say that you had a screening colonoscopy, and it was charged for outpatient surgery. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 $325 copayment for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility.
You have been asked to pay a $325 copayment for a colonoscopy. The Plan contract says that when a screening colonoscopy becomes a diagnostic procedure (results in a biopsy or removal of a lesion or growth), then outpatient surgery cost sharing may apply. The records show you had a polyp removed and sent to a pathologist. The EOC confirms $325 is the required copayment for this service. A colonoscopy falls within the outpatient hospital 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 copayment for a colonoscopy (45385) provided on April 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the drugs you received from January 8, 2021, to January 25, 2021.

You asked the Plan to waive the coinsurance. The Plan denied your request. The Plan says you have been asked to pay 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 19% coinsurance for Medicare-covered Part B prescription drugs and chemotherapy drugs. 

Review of the file shows that you were provided Part B covered drugs from January 8, 2021, to January 25, 2021. You have been asked to pay a 19% coinsurance for the services. The drugs fall within the Medicare-covered Part B prescription 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 drugs you received from January 8, 2021, to January 25, 2021.