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

We decided that the Plan does not have to pre-approve hypertrophic cardiomyopathy genome panel for the enrollee.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says there is no clinical history concerning for acquired hypertrophic cardiomyopathy.
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 testing. Our reviewer says that the requested testing is not considered medically reasonable and necessary in this case. Our physician reviewer found a hypertrophic cardiomyopathy genome panel is not medically reasonable and necessary in this case, as there is no family history or clinical suspicion of a specific genetic condition known to cause left ventricular hypertrophy, or a first degree family member with hypertrophic cardiomyopathy and a definitively identified gene-causing mutation. The available documentation in the case file does not support that the requested hypertrophic cardiomyopathy genome panel would impact the management and outcome of 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 the testing have not been met. Therefore, we decided that the Plan does not have to pre-approve hypertrophic cardiomyopathy genome panel for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay in full for the periodic oral evaluation (D0120), bitewing x-rays (D0277), and prophylaxis (D1110) provided on January 7, 2021 by an OON provider.
You asked the Plan to pay in full for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that your benefit information does not state that the Plan will only pay a portion of the cost for OON charges. The Plan denied your request. The Plan says if you receive covered services from an OON provider you will be responsible for the cost-sharing shown, plus any difference between the amounts the Plan pays the provider and the provider's billing amount.
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, you are responsible for the difference between the billed amount and allowed amount for covered services received OON. Therefore, we decided that the Plan does not have to pay in full for the periodic oral evaluation (D0120), bitewing x-rays (D0277), and prophylaxis (D1110) provided on January 7, 2021 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on January 8, 2021.
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You say that you are unable to pay for this bill because you live on a fixed income. The Plan denied your request. The Plan says these services do not meet the frequency requirements of 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, comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) on August 13, 2020, and your comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on January 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on November 12, 2020.
You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says the billed services are not supported.
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 medical records from the ordering physician or documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing provided on November 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on March 16 to March 22, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you should not be responsible for the hospital stay due to hygiene practices at the hospital not being up to par. 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). Your contract with the Plan clearly says that you must pay a $150 copayment for per day for days 1 to 8 of an inpatient hospital stay. You have been asked to pay $900, or a $150 copayment per day for a 6-day stay for inpatient hospital care. 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 inpatient hospital care provided on March 16 to March 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by participating providers on September 9, 2020, to January 26, 2021.
You asked the Plan to waive the copayment for a specialist office visit. You say that you should not be charged two copayments for one day just because you were seen by two doctors. The Plan denied your request. The Plan says the correct copayments have 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 $45 copayment and a $40 copayment for physician/practitioner services/in-network/specialist.
You have been asked to pay a $45 copayment and a $40 copayment for a specialist office visit. The total amount you are being asked to pay is $220 ($45 copayment x 4 visits (2020) + $40 copayment (2021) = $220). A specialist office visit falls within the physician/practitioner services/in-network/specialist benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist office visit provided by participating providers on September 9, 2020, to January 26, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that it is not safe for the enrollee to be discharged. The Plan denied your request. The Plan says that the enrollee does not require skilled nursing services on a daily basis.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 5, 2019.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the claim was received past the allowed 12-month time frame.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for the physician's services was not filed until December 7, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for physician's services provided on October 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve Euflexxa. You say that your knees are rubbing bone to bone and the pain is unbearable. The Plan denied your request. The Plan says that you do not meet the step therapy requirements for this drug.
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 Euflexxa. Our reviewer says that Euflexxa is not medically reasonable and necessary. The provided records do not clearly show that you have tried and failed Durolane, Gelsyn-3, or Synvisc/Synvisc-One. The records do not describe a unique clinical situation where the requested Euflexxa would likely be more effective or safer for you as all hyaluronic acid derivative injections have been shown in currently available literature to be essentially equally safe and effective. Our physician reviewer found that your condition does not meet Medicare criteria for Euflexxa. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary for the enrollee. The Plan denied your request. The Plan says that continued management can be provided in the acute care hospital until your course of care is complete.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management (99238) provided on
September 21, 2020.
You asked the Plan to pay for the evaluation and management service. You say that the services were
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 hospital discharge day management (99238) provided on
September 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network ophthalmologist.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there is no gap issue and there are in-network providers available.
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 to an out-of-network ophthalmologist.
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
February 17, 2021.

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 February
17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient stay provided from May 15, 2019, through
May 25, 2019.
You asked the Plan to pay for the inpatient stay. You say that while you were on vacation in Bermuda, you had taken a fall and fractured your leg. You say that you needed emergency services and had to remain in the hospital for days and following surgery, you had to be flown home with a medical team and were in a rehab facility for several weeks. The Plan denied your request. The Plan says without supportive documentation the Plan has denied the services as not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.
We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical documents to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of the inpatient stay have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient stay provided from May 15, 2019, through May 25, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia for other procedure on skin of arms, legs, and front body (00400) provided on July 20, 2020.
You asked the Plan to pay for the anesthesia. You say that the treatment provided was not due to the enrollee's hospice diagnosis. 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. 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 July 3, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the anesthesia for other procedure on skin of arms, legs, and front body (00400) provided on July 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology services provided on December 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the services provided. You say that the services were medically necessary in providing a medical diagnosis for the enrollee. The Plan denied your request. The Plan says services rendered by non-participating providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The 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 pathology services provided on December 23, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
You asked the Plan to pre-approve Vertiflex. You say that this treatment is considered safe and effective, and
the enrollee is a good candidate for it. The Plan denied your request. The Plan says the denial of authorization
for this service is correct, because Vertiflex is experimental/investigational.
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 Vertiflex. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found Vertiflex is investigational/experimental, and the enrollee is not receiving this device as part of
a Medicare-covered clinical trial.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have
to pre-approve insertion of an interspinous spacer device (Vertiflex).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for scanning computerized ophthalmic diagnostic imaging (92133) provided January 22, 2021.
You asked the Plan to waive the copayment for the diagnostic services. You say that you should not have to pay a separate copayment for diagnostic testing services and would like this copayment removed. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.
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 $50 copayment for covered outpatient diagnostic tests. You have been asked to pay $41.31 for the diagnostic services. Since the allowed amount was less than the
copayment amount, you are responsible for the lesser amount. The diagnostic 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 scanning computerized ophthalmic diagnostic imaging (92133) provided January 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pharmacogenetic testing (81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241,81247, 81283, 81291, 81306, 81328, 81335, 81350, 81355, 81381, 81400, 81401, 81403, 81406 and 81407) provided on October 23, 2020.

You asked the Plan to pay for pharmacogenetic testing. You say that the billed codes are valid. The Plan denied your request. The Plan says the services at issue were not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. If a laboratory assays two or more genes in a
patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the panel.

We find that CPT codes 81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241,81247, 81283, 81291, 81306, 81328, 81335, 81350, 81355, 81381, 81400, 81401, 81403, 81406 and 81407 are not supported in the medical record. Specifically, the record shows that this testing was performed as a panel and should be reported with a single code. Based on this information, we decided that Medicare rules for coverage of pharmacogenetic testing have not been met. Therefore, we decided that the Plan does not have to pay for pharmacogenetic testing (81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241,81247, 81283, 81291, 81306, 81328, 81335, 81350, 81355, 81381, 81400, 81401, 81403, 81406 and 81407) provided on October 23, 2020.