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

We decided that the Plan does not have to waive the copayment for an X-ray (71046) provided on May 3, 2019.
You asked the Plan to waive the copayment for the x-ray. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied.
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 a $50 copayment. for outpatient diagnostic test and therapeutic services. The enrollee has been asked to pay a $50 copayment for the x-ray. The x-ray falls within the outpatient diagnostic test and therapeutic services 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 an X-ray (71046) provided on May 3, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on October 3, 2018.
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 procedure code 27299 is not supported.
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 27299 is unlisted procedure, pelvis or hip joint. We find that CPT code 27299 is not supported in the medical record. Specifically, the records do not include documentation of an unlisted procedure of the pelvis or hip joint. 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 pay for the services rendered to the enrollee on October 3, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on September 4, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not billed correctly.The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for an independent laboratory; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11.Therefore, we decided that the Plan does not have to pay forthe drug testing rendered on September 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount forthe limited oral evaluation (D0140), the initial periapical x-ray (D0220), and the root canal fora premolar tooth (D3320), and the root canal for a molar tooth (D3330) provided from May 16, 2019 to August 2, 2019 by the out of network provider.You asked the Plan to pay the full amount for. You say that the root canals were emergencies. You say that you believe your policy has Preventive Max--Multiplier which covers the cost of an emergency over and above your annual maximum. You also say that an in network provider could not see you for 12 days.The Plan denied your request. The Plan says your benefit maximum has been exhausted. The Plan says that the provider in this case is not a network provider with the Plan. The Plan also says that the Platinum Dental Rider does not have a "Preventive Max Multiplier" benefit and is not offered through Medicare plans.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 and the dental services are listed as covered, the annual maximum has been exceeded. (D0140), the initial periapical x-ray(D0220), and the root canal for a premolar tooth (D3320), and the root canal for a molar tooth (D3330) provided from May 16, 2019 to August 2, 2019 by the out of network provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve PET scan of the heart for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says that this is needed for proper cardiac medical management to be done.
The Plan must follow Medicare rules. Medicare rules say that PET 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 scan is medically reasonable and necessary. Our physician reviewer found the enrollee has equivocal symptoms as well as discordant and equivocal stress echo which together provide a valid indication per NIA guidelines for PET myocardial perfusion study. 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 been met. Therefore, we decided that the Plan has to pre-approve PET scan of the heart for the enrollee.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe 4+ surface silver filling and 3 surface silver filling provided on October 2, 2019.You asked the Plan to pay forthe 4+ surface silver filling and 3 surface silver filling. You say that you confirmed with the Plan that this provider is a participatingdentist.The Plan denied your request. The Plan says you received multi-surface white fillings on your back teeth. The Plan also says that multi-surface white fillings on back teeth are excluded.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 contract says that multi-surface fillings will be processed as a silver filling and you will be responsible for up to the contracted fee. The Plan contract says that white fillings on back teeth are only covered for single surfaces. The record shows that you received multi-surface fillings on tooth #'s 4 and 5 and you are responsible for paying the contracted fee for these services.Therefore, we decided that the Plan does not have to pay forthe 4+ surface silver filling and 3 surface silver filling provided on October 2, 2019.
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-approvethe LTACH services. You say that the requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.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 admission to a LTACH is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for complications following surgery for pancreatic cancer. The enrollee has received antibiotics and supplemental nutrition. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of carefor any ongoing long term care needs.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-approvelong term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiac rehabilitation with an out-of-area provider.You asked the Plan to pre-approve these services. You say that you had a heart attack and need cardiac rehab.The Plan denied your request. The Plan says the services are available from in-area, in-network providers.Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.  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 do not meet the out-of-area criteria for coverage. Our physician reviewer found the records show that you had a heart attack on January 23, 2020 that was treated with a stent placement. The requested cardiac rehabilitation services are not urgent in nature, as it would be safe to delay services until you return to the plan's service area in a month's time. The out-of-area services are therefore 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-approvecardiac rehabilitation with an out-of-area provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz FX.You asked the Plan to pre-approve Supartz FX. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee has not tried Monovisc and Orthovisc as required by step therapy rules.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 Supartz FX. Our reviewer says that the criteria for coverage of Supartz FX have not been met. Our physician reviewer found the documentation does not support that the enrollee has tried and failed Monovisc and Orthovisc, or that these drugs would likely be less effective or 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 Supartz FX have not been met.Therefore, we decided that the Plan does not have to pre-approve Supartz FX.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe 2colonoscopies provided from April 16, 2019 to April 18, 2019.You asked the Plan to pay forthe surgical services. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as itis 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 servicesand to know proper billing procedures for a Medicare Advantage enrollee on hospice.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.The enrollee ended Medicare Hospice benefits on April 2, 2019. The services in question were provided before the end of that month.Therefore, we decided that the Plan does not have to pay forthe 2colonoscopies provided from April 16, 2019 to April 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services (CPT 81545) provided to the enrollee on May 11, 2019.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says there are no records provided which would show that coverage criteria are met.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. The documentation submitted by the non-contract provider only contains the laboratory request form and no office notes from the ordering provider. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services (CPT 81545) provided to the enrollee on May 11, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.You asked the Plan to pay forthe ambulance services. You say that the claim must be paid by your insurance. You asked the Plan to reprocess the denied claim.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on October 29, 2019. 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 forthe ambulance services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Zilretta.
You asked the Plan to pre-approve Zilretta. You say that you are appealing based on medical necessity. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because Zilretta is not approved for repeat use and the record shows that the enrollee has used this drug before.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Zilretta. Our reviewer says that the enrollee does not meet the Medicare criteria for use of Zilretta. Our physician reviewer found Zilretta is experimental for the treatment of knee degenerative joint disease, and more research is needed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Zilretta.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the office visit provided on August 29, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you should not be responsible for the copayment because you only had lab work completed and did not have an office visit. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. There was no claim form or medical records submitted with the code at issue to verify the billed service. Therefore, the plan has not shown that the copayment amount you are being asked to pay is correct or justified by the health plan contract. Therefore, we decided that the Plan has to waive the copayment for the office visit provided on August 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit provided on September 4, 2019 to September 16, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe office visit. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered 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 forthe office visit provided on September 4, 2019 to September 16, 2019 by an outof network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Decipher prostate cancer classifier assay provided  on May 30, 2019.You asked the Plan to pay for genetic test. You say that this test was ordered because it was medically necessary.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this test did not meet the Medicare guidelines for coverage.The Plan follows Medicare rules. Medicare rules say that Decipher prostate cancer classifier assay is covered only when the enrollee meets certain specific criteria.
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 test. Our reviewer says that this testing does not meet the Medicare criteria for coverage. Our physician reviewer found the surgical pathology report of medical records do not indicate the presence of adverse pathology and rising prostate specific antigen (PSA) after initial PSA nadir has not been confirmed.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 test have not been met. Therefore, we decided that the Plan does not have to pay for Decipher prostate cancer classifier assay provided on May 30, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management provided on August 30, 2019.
You asked the Plan to pay for the hospital discharge day management. You say that the enrollee was not enrolled in hospice at the time of service. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
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 the hospital discharge day management provided on August 30, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe first hour of critical care, the additional 30 minutes of critical care, and the intubation provided on July 28, 2018.You asked the Plan to pay forthe emergency room services. You say that  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 thelast day of the month in which hospice is revoked.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 forthe first hour of critical care, the additional 30 minutes of critical care, and the intubation provided on July 28, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for assisted living care provided on September 4, 2019 by an out of network (OON) provider.You asked the Plan to pay forassisted living care. You say that our provider treated the member.. You say that the provider cannot deny any medical services that were essential for patient health treatment.The Plan denied your request. The Plan says the referring facility is out-of-network. The Plan says that no prior authorization was obtained 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 forassisted living care provided on September 4, 2019 by an out of network (OON) provider.