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

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on January 11, 2021.
You asked the Plan to pay for the office visit. You say that the denial should be reconsidered due to medical necessity and the claim should be processed for payment. The Plan denied your request. The Plan says prior authorization was required but 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on January 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on October 31, 2020.
You asked the Plan to pay for the services. You say that you did not know that authorization was required. The Plan denied your request. The Plan says the services were not authorized.
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 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 services provided to you by an out-of-network provider on October 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient mental health facility for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says treatment at a lower level of care is appropriate.
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 the admission. Our reviewer says that
the requested admission is not medically reasonable or necessary. Our physician reviewer found based on a
review of the records provided, it was not expected this enrollee would improve in a reasonable period of time
for the dates in question as she did not have suicidal or homicidal ideation noted and no auditory or visual
hallucinations. There are no abnormal or aggressive behaviors or symptoms that would require acute treatment.
The enrollee has been given no medication for treatment. It did not appear medically necessary and reasonable
to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the
dates in question as she did not have dangerousness to self or others. The health plan's denial of continued
inpatient psychiatric services is appropriate.
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 admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to an inpatient mental health facility for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Genvisc 850 injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the step therapy criteria has not been met.
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 the injection. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. In this case, the patient has not tried and failed the required drugs. There is no documentation provided indicating that the Plan's required drugs would likely be less effective and/or likely have adverse effects 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 the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Genvisc 850 injection for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for total prostate specific antigen (PSA) testing provided on February 10, 2021.
You asked the Plan to pay for total PSA test. You say that this test was always covered in the past. The Plan denied your request. The Plan says the denial of payment for this test is correct, because this test was not performed for a covered diagnosis and is not covered for screening purposes.
The Plan must follow Medicare rules. Medicare rules say that PSA total testing is only covered when performed for a diagnosis of elevated PSA. We looked at the file and Medicare rules. This test was not performed for a covered diagnosis. You were given prior notice that this testing would not be covered, and acknowledged that you understood you may be responsible for the entire cost of the service. Based on this information, we decided that Medicare rules for coverage of total PSA test have not been met. Therefore, we decided that the Plan does not have to pay for total prostate specific antigen (PSA) testing provided on February 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oncology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve OON services. You say that the enrollee has not been helping the enrollee thrive. The Plan denied your request. The Plan says there is appropriate care available within the plan.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve oncology services to be provided 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 services provided by an out-of-network provider on July 17, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 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 services provided by an out-of-network provider on July 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), and the intraoral
- complete series of radiographic images (D0210) received February 15, 2021.
You asked the Plan to pay for the comprehensive oral evaluation and the intraoral complete series of
radiographic images. You say that you cannot afford to pay the bill and you were not informed what the
frequency limitation would be for these services. The Plan denied your request. The Plan says benefits for these
services have 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, the requested items or services are not
among those covered under this benefit. The Plan limits coverage of comprehensive oral evaluations to once
every three years, and limits coverage of intraoral radiographic imaging procedures to once every five years.
The Plan has submitted evidence that you last received these services, for which reimbursement was issued, on
November 19, 2019. Your benefit for these procedures was exhausted on February 15, 2021. Therefore, we
decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), and the intraoral -
complete series of radiographic images (D0210) received February 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic tests provided by an opted-out physician on January 11, 2021.
You asked the Plan to pay for diagnostic tests. You say that you hope you can be reimbursed for these services. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider has opted out of Medicare and is not payable.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for diagnostic tests provided by an opted-out physician on January 11, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services you received on July 15, 2020.
You asked the Plan to pay for the services. You say that you didn't know this wouldn't be paid for. The Plan denied your request. The Plan says that the services were provided outside of your medical group.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for the services by a contract provider. The file does not show that the Plan provided notice that the services would not be covered. Under Medicare rules, this means the services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the services you received on July 15, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the Covid-19 testing with amplified probe technique, making use of high throughput technologies (U0003), and the Covid 19-testing with amplified probe technique (U0005) provided on January 19, 2021.
You asked the Plan to pay for the laboratory services. You say that the services are medically necessary. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in
which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
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 date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the Covid-19 testing with amplified probe technique, making use of high throughput technologies (U0003), and the Covid 19-testing with amplified probe technique (U0005) provided on January 19, 2021.
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 you need inpatient rehabilitation as you can barely
move or ambulate. The Plan denied your request. The Plan says the clinical assessment does not indicate that
you require or would be able to actively participate in 3 hours per day, at least 5 days weekly, of intensive
rehab therapy. You will not require face to face medical supervision by a rehab physician 3 times per week, nor
do the records indicate that you will require complex medical management that would warrant an
interdisciplinary approach to providing rehabilitation. The required skilled rehab and nursing services can
safely and effectively be provided at a lower level of care.
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 your nursing, medical and rehabilitation needs does not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require
physical and occupational therapy but there is no documented need for an intensive rehabilitation program.
There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive
rehabilitation therapy program provided in an IRF. Medically necessary services can be provided in a different
level of care.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider from November 2, 2020, to November 10, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were no urgent or emergent.
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 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 services provided by an out-of-network provider from November 2, 2020, to November 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation - per quadrant (D4921) received
March 19, 2021.
You asked the Plan to pay for the gingival irrigation. You say that you are on a fixed income and cannot afford
this procedure. You were not told which providers would be a participating provider. The Plan denied your
request. The Plan says regardless of whether the service is performed by a network or out-of-network provider,
gingival irrigation is not a covered service under your supplemental 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. The gingival irrigation would not be covered regardless of the network
status of the dental provider. Therefore, we decided that the Plan does not have to pay for the gingival irrigation
- per quadrant (D4921) received March 19, 2021.
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 these services are medically necessary. The Plan denied your request. The Plan says that LTACHs do not provide clinical advantage over a non-LTACH acute care hospitals.
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 were admitted following acute on chronic respiratory failure due to aspiration pneumonia. You continue to receive acute care services, and these have not been denied. The medical record does not indicate that you require services that you are not currently receiving but that would be available at the LTACH facility. Our physician reviewer found that your 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.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomographic (CT) colonography (74261, 74263).
You asked the Plan to pre-approve the CT colonography. You say that you attempted and failed a colonoscopy on November 16, 2020. Further information should be in your patient file with your primary doctor. Please note this test is past due for you and you are a cancer survivor. The Plan denied your request. The Plan says it is not a medical necessity to approve the requested CT colonography.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the CT colonography. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case the requested service is for screening purposes. The enrollee cannot tolerate an oral bowel prep. This s not a covered indication for the requested test under Medicare rules. The local coverage determination states that virtual colonoscopy is not covered when used as an alternative to instrument colonoscopy for screening or in the absence of signs or symptoms of disease. The elements of the coverage determination are not satisfied. 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 CT colonography have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomographic (CT) colonography (74261, 74263).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services coded as 98943, 97012, 97140 and 98942 provided on January 21, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the chiropractic services. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the chiropractic services coded as 98943, 97012, 97140 and 98942 provided on January 21, 2021 by an out of network (OON) provider.