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

We decided that the Plan does not have to pay for laboratory testing provided on October 7, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for laboratory testing. You say that this testing was medically necessary and the enrollee did not have an in-network option for this testing. The Plan denied your request.

The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with 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 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 laboratory testing provided on October 7, 2020 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve allograft for spinal surgery for the enrollee. 
 
You asked the Plan to pre-approve the allograft. You say that this is medically necessary. The Plan denied your 
request. The Plan says the surgery is happening in the neck with an anterior approach. 
 
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 allograft. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the medical records do not show an approved indication for the use of allograft in this case. It is not 
approved by the Food and Drug Administration (FDA) for use in the cervical spine for fusion surgery. High 
complication rates have been reported. 
 
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 allograft have not been met. Therefore, we decided that the Plan does not 
have to pre-approve allograft for spinal surgery for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Omeprazole.
You asked the Plan to pre-approve Omeprazole. You say that the drug is medically necessary. The Plan denied your request. The Plan says this is a self-administered drug.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Omeprazole.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for telemedicine services provided on January 20, 2021 by an
out-of-network (OON) provider.
You asked the Plan to pay for telemedicine services. You say that you would like this claim reprocessed and
paid. The Plan denied your request. The Plan says prior authorization was not 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 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 telemedicine services provided on January 20,
2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing provided on December 28, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the lab services. You say that you are not responsible for obtaining prior authorization. The Plan denied your request. The Plan says no authorization has been 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 provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the lab testing provided on December 28, 2020 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the prophylaxis (D1110) provided on April 19, 2021 by
an OON provider.
You asked the Plan to pay more for the prophylaxis. You say that you did not know, nor were you advised, that
the treating provider was not in-network. The Plan denied your request. The Plan says the total $80.00 amount
applied correctly as member liability. The Plan also says that cost sharing is a contractual obligation under the
Plan and cannot be waived.
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 more for the prophylaxis (D1110) provided on April 19, 2021 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nerve conduction studies (95908) provided on March 9, 2021.
You asked the Plan to pay for nerve conduction studies. You say that this was performed to diagnose and evaluate nerve disorders. The Plan denied your request. The Plan says this is not documented.
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 95908 is nerve conduction studies; 3-4 studies. We find that CPT code 95908 is not supported in the medical record. Specifically, there is no documentation of nerve conduction studies being performed.
Based on this information, we decided that Medicare rules for coverage of nerve conduction studies have not been met. Therefore, we decided that the Plan does not have to pay for nerve conduction studies (95908) provided on March 9, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the myocardial perfusion imaging, tomographic (78452), cardiovascular stress test (93015), technetium tc-99m tetrofosmin, diagnostic, per study dose (A9502), and the technetium tc-99m sestamibi, diagnostic, per study dose (A9502) provided on March 29, 2021.
You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the services provided.
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 $110 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic), a $30 copayment for Medicare-covered non-radiological diagnostic services, and a 20% coinsurance for each Medicare-covered medical supply. Supplies for which an appropriate separate charge is made by providers (such as chemical agents used in certain diagnostic procedures) are subject to cost-sharing. You have been asked to pay $186.56 which includes a $110 copayment for the Medicare-covered radiological diagnostic service, a $30 copayment for the Medicare-covered non-radiological service, and the Plan allowed amount of $232.80 x 20% coinsurance=$46.56 for the Medicare-covered medical supplies provided. 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 cost share for the myocardial perfusion imaging, tomographic (78452), cardiovascular stress test (93015), technetium tc-99m tetrofosmin, diagnostic, per study dose (A9502), and the technetium tc-99m sestamibi, diagnostic, per study dose (A9502) provided on March 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid, digital, monaural (V5257), dispensing fee,
monaural hearing aid (V5241), fitting/orientation/checking of hearing aid (V5011), and ear mold/insert, not
disposable, any type (V5264) provided March 10, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the hearing aid, dispensing fee, hearing aid fitting and ear mold. You say that the
provider is in-network and the claim should be reprocessed. The Plan denied your request. The Plan says the
provider is not part of the Plan's hearing network and prior authorization for the services was not obtained,
therefore the services are not covered.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids up to $1,000 credit every three years when provided by a network provider. We looked at the file and the Plan's rules. In this case it appears that services were provided by an out-ofnetwork
provider. 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. Based on this information, we decided that the Plan's rules for
coverage of the hearing aid, dispensing fee, hearing aid fitting and ear mold have not been met. Therefore, we
decided that the Plan does not have to pay for the hearing aid, digital, monaural (V5257), dispensing fee,
monaural hearing aid (V5241), fitting/orientation/checking of hearing aid (V5011), and ear mold/insert, not
disposable, any type (V5264) provided March 10, 2021 by an out-of-network (OON) provider.
Non-contract provider appeals require a Waiver of Liability form indicating that the enrollee is not being held
responsible for the items or services at issue. In this case, you signed and completed a Waiver of Liability form,
indicating that you are a non-contract provider.
You claim that you are a contract provider with the Plan. Contract providers do not have appeal rights through
the Independent Review Entity (IRE) process. If you are indeed a contract provider with the Plan, you will
need to contact the Plan directly regarding any appeal processes that they have for contract providers.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aduhelm (J3590).

You asked the Plan to pre-approve Aduhelm. You say that you would like Aduhelm to be approved for the enrollee's early Alzheimer disease. The Plan denied your request. The Plan says the use of Aduhelm for this enrollee is not reasonable and necessary.

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 Aduhelm. Our reviewer says that Aduhelm (J3590) is not medically reasonable and necessary for the enrollee. Our physician reviewer found Aduhelm is indicated for the treatment of Alzheimer's disease in patients with mild cognitive impairment or the mild dementia stage of the disease. The documentation is insufficient to confirm a diagnosis of Alzheimer's disease in this enrollee. The cerebrospinal fluid evaluation was not consistent with Alzheimer's disease, and a magnetic resonance imaging suggests the presence of cerebrovascular disease, which is evidence of a mixed etiology for the enrollee's symptoms. Our reviewer found that the documentation does not support that the Aduhelm (J3590) is safe and effective for the enrollee. Our physician reviewer also found that the documentation is insufficient to confirm a diagnosis of mild cognitive impairment due to Alzheimer's disease.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have to pre-approve Aduhelm (J3590).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services provided on May 17, 2021.
You asked the Plan to waive the copayment for lab services. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for lab services provided at a freestanding laboratory. The record shows that you received lab services at a freestanding laboratory on May 17, 2021. Therefore, you are responsible to pay the $20 copayment. You have been asked to pay a $20 copayment for lab services. Lab services fall within the outpatient diagnostic tests and therapeutic services and supplies 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 lab services provided on May 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on March 10, 2021, by an OON provider.
You asked the Plan to pay for lab tests. You say that these services are payable as billed and coded by your office. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and the ordering provider was also out-of-network with 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 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 laboratory testing provided on March 10, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show improvement with the prior injections. 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee's back pain is repeatedly described as radiating to the right knee and to the toes. The pain 
described throughout is that of radicular pain. Thus, with the enrollee having radicular pain, facet injections are 
not indicated. The facet joint is not the main source of pain. The enrollee did not get the proper relief from prior 
injections. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for physician services provided on October 8, 2020 for code 99213.
You asked the Plan to pay for these services. You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says the provider needs to submit a corrected claim with supporting medical records to have code 99213 paid. The Plan reiterates that this corrected information must come directly from the provider.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. This provider is out of network and therefore, the Plan cannot compel the provider to resubmit this claim. Had you used an in-network provider; the Plan would have been able to hold you harmless for these charges other than your normal copayment. Until the provider resubmits this claim, the Plan cannot hold you harmless for these charges. Therefore, we decided that the Plan does not have to pay for physician services provided on October 8, 2020 by Kelly Malinoksi, MD for codes 99213 and L3000.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide additional routine transportation beyond the Plan's 50-trip limit.
You asked the Plan to provide additional routine transportation. You say that you have appointments you must go to and no other source of transportation. The Plan denied your request. The Plan says additional routine transportation is not covered for any reason.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 50 trips per year.
We looked at your request, the records in the case file, and the rules. Your request for additional transportation exceeds the Plan's 50-trip limit. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide additional routine transportation beyond the Plan's 50-trip limit.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular testing (81407, 81479, 81405, 81406, 81286, 81403, 81408, 81404) provided February 24, 2021.
You asked the Plan to pay for cardiovascular testing. You say that this testing was specifically requested by the enrollee's physician. The Plan denied your request. The Plan says this service is not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The testing at issue in this appeal, cardiovascular testing, was requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for cardiovascular testing (81407, 81479, 81405, 81406, 81286, 81403, 81408, 81404) provided February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an annual physical provided on May 17, 2021 and billed under code 99387.
You asked the Plan to pay for this service. You say that this was an annual physical and should be covered by the Plan. The Plan denied your request. The Plan says the provider is billing for codes that are not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. A full physical coded as 99387 is not covered by Medicare. Because the provider is out of network, the Plan cannot compel the provider to submit a corrected claim. Therefore, we decided that the Plan does not have to pay for an annual physical provided on May 17, 2021 and billed under code 99387.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on January 6, 2021, to March 24, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for an office visit. You say that this provider is closer to the member's home. The Plan denied your request. The Plan says there are in-network providers available. The Plan says that the member's primary care physician did not refer 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 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 an office visit provided on January 6, 2021, to March 24, 2021 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 dental services provided March 4, 2021.
You asked the Plan to pay for the dental services. You say that you would like this claim reprocessed and approved for payment since you were unaware this policy was cancelled. The Plan denied your request. The Plan says the previous group contract was terminated, and no payment is due at this time.
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. The Plan covers the dental services when the services are rendered by a non-participating provider.
We looked at the file and Medicare rules. In this case, the case file indicates that the services were rendered by a non-participating provider. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pay for the dental services provided March 4, 2021.