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

We decided that the Plan does not have to pre-approve polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep (95811).
You asked the Plan to pre-approve a polysomnography study. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a polysomnography study. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in the case of this enrollee with a history of sleep apnea, a supervised in-office polysomnography test was ordered and requested for coverage. However, the records provided did not clearly show evidence of a contraindication for an at-home auto-titrating PAP (APAP) machine which is preferred and equally effective if no complicating medical conditions exist, of which there is no evidence in this case. Therefore, without sufficient support made for this request, the attended polysomnography positive airway pressure study will be considered not 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 a polysomnography study have not been met. Therefore, we decided that the Plan does not have to pre-approve polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep (95811).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periapical dental x-ray provided on January 7, 2020.
You asked the Plan to pay for the x-ray. The Plan denied your request. The Plan says that this is not covered by
the Plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
periapical dental x-ray provided on January 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on January 2, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says there is no
documentation of a diagnosis for which testing may be done.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The testing at issue in this appeal, the lab services, 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 the lab
services provided on January 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
You asked the Plan to pre-approve additional routine transportation trips. You say that the requested services are necessary for the enrollee to be able to get to medical appointments. The Plan denied your request. The Plan says the requested additional transportation trips exceed the benefit limit. Therefore, coverage criteria has not been met.
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 24 one-way transportation trips per year. We looked at your request, the records in the case file, and the rules. 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 pre-approve additional routine transportation trips (A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered on January 27, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility. Therefore, we decided that the Plan does not have to pay for the special pump services rendered on January 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 22, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency 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 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 medical services provided to the enrollee by an out-of-network provider on October 22, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided to the enrollee on August 27, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says this provider has opted out of Medicare.The Plan must follow Medicare rules. The rulessay 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 thisappeal were provided in a non-urgent, non-emergent situation by a provider has opted out of the Medicare program.Therefore, we decided that the Plan does not have to pay forthe physician services provided to the enrollee on August 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bitewing x-rays (D0274) provided on November 25, 2019.
You asked the Plan to pay for bitewing x-rays. You say that you shouldn't have to pay for this because your
dentist gave you the wrong x-ray. 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 bitewing
x-rays (D0274) provided on November 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve monitored anesthesia care during a colon cancer screening.
You asked the Plan to pre-approve the anesthesia. You say that this is medically necessary. The Plan denied your request. The Plan says the medical records do not show a documentation for the following risk factors: morbid obesity with a BMI over 40, and stops breathing while sleeping.
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 anesthesia. Our reviewer says that the requested anesthesia is not considered medically reasonable and necessary in this case. Our physician reviewer found you have no known medical conditions. The review indicates that you fail to meet any of the accepted criteria for MAC for endoscopic procedures. If there is a COVID-19 concern you should have a COVID screening test performed prior to the procedure. The requested service for MAC in this case is not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the anesthesia have not been met. Therefore, we decided that the Plan does not have to pre-approve monitored anesthesia care during a colon cancer screening.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on January 20, 2020.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered on January 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a denture repair (D5512, D5520) provided January 15, 2020.
You asked the Plan to pay for the denture repair. You say that the services were medically necessary. The Plan denied your request. The Plan says the services are not covered under the plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a denture repair (D5512, D5520) provided January 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D0272, D0230, D0220, D0330) provided January 13, 2020.You asked the Plan to pay for the dental services. You say that the services should be covered.The Plan denied your request. The Plan says your dental benefit only covers services provided in-network.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's dental coverage only covers items when they are received from in-network providers.Therefore, we decided that the Plan does not have to pay fordental services (D0272, D0230, D0220, D0330) provided January 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an adjunctive pre-diagnostic dental test (D0431) provided on January 21, 2020.
You asked the Plan to pay for an adjunctive pre-diagnostic dental test. You say that you don't believe this service was performed. The Plan denied your request. The Plan says this processed correctly.
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 an adjunctive pre-diagnostic dental test (D0431) provided on January 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services provided on December 3, 2019 by an out of network (OON) provider.
You asked the Plan to pay for pathology services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is out-of-network. 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for pathology services provided on December 3, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance foran injection provided by a participating hospital on November 8, 2019.You asked the Plan to waive the coinsurance foran injection. You say that you never had this high of a coinsurance before.The Plan denied your request. The Plan says the correct coinsurance has been 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). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $4,013.10. The total amount you are being asked to pay is $802.62 ($4,013.10 x 20% = $802.62). An injection falls within the Medicare 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 foran injection provided by a participating hospital on November 8, 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-approve the LTACH services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are 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 services are not medically necessary. Our physician reviewer found the enrollee is currently undergoing treatment at an ACH for a chronic, infected, sacral wound. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. 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.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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued inpatient psychiatric care beyond May 4, 2020.You asked the Plan to pre-approvethe continued inpatient psychiatric care. You say that the enrollee would benefit from continued care in the inpatient setting.The Plan denied your request. The Plan says the enrollee's needs can now be met in a less restrictive setting.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 continued inpatient psychiatric care. Our reviewer says that the requested continuation of inpatient care is not considered medically reasonable and necessary. Our physician reviewer found this 64-year-old male was admitted to the acute inpatient psychiatric hospitalization on March, 2020 with Schizoaffective Disorder. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others without aggressive behaviors. 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 he did not have any suicidal or homicidal thoughts or abnormal behaviors. The health plan's denial of continued inpatient psychiatric services appears appropriate. This enrollee did not require inpatient mental health treatment beyond the dates in question as noted above as he was not a danger to himself or others and did not have any agitation or aggression but is compliant with treatment. It did not appear that active treatment was taking place beyond thedate in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the patient's condition or for the purpose of diagnosis.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 continued inpatient psychiatric care have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued inpatient psychiatric care beyondMay 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for a second opinion at an out-of-network provider.You asked the Plan to pre-approve the referral. You say that this is medically necessary.The Plan denied your request. The Plan says an in-network provider has been 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 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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve a referral for a second opinion at an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found Keytruda is not FDA-approved as second line therapy for PD-L1 zero percent non-small cell lung cancer (NSCLC) patients. The use of Keytruda for the enrollee is not supported by major drug compendia and is not the standard of care. Keytruda is not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to reimburse you for a tissue transfer (14040) provided on June 4, 2019.
You asked the Plan to reimburse you for a tissue transfer. You say that you paid out-of-pocket for this medically necessary service. The Plan denied your request. The Plan says that this service was billed with an inappropriate modifier.
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. the enrollee was referred for a tissue transfer by the MD. The MD is a contract provider. The file does not show that the plan provided notice that a tissue transfer would not be covered. Under Medicare rules, this means a tissue transfer is considered approved by the plan. Therefore, we decided that the Plan has to reimburse you for a tissue transfer (14040) provided on June 4, 2019.