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

We decided that the Plan does not have to pay for a general health panel (80050) provided on May 11, 2020.
You asked the Plan to pay for a general health panel. You say that this is supported by the records. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-covered code. You have requested payment for services billed under code 80050. Medicare does not cover or pay for services billed under this code. Therefore, we decided that the Plan does not have to pay for a general health panel (80050) provided on May 11, 2020.
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 you are failing to thrive but need to get out of the hospital and continue care as you are unable to care for yourself. The Plan denied your request. The Plan says that your record does not show that you require daily skilled nursing or skilled therapy in a SNF setting.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210), first 15 minutes of intravenous moderate (conscious) sedation/analgesia (D9239), and each subsequent 15 minute increment of intravenous moderate (conscious) sedation/analgesia (D9243) provided on April 15, 2021.
You asked the Plan to pay for the surgical extraction and intravenous moderate (conscious) sedation/analgesia services. You say that you were advised that you would need to have tooth extractions performed by an oral surgeon. You also say that you believe this service should be covered. The Plan denied your request. The Plan says these services are purely dental in nature and are unrelated to the limited clinical indications.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the surgical extraction (D7210), first 15 minutes of intravenous moderate (conscious) sedation/analgesia (D9239), and each subsequent 15 minute increment of intravenous moderate (conscious) sedation/analgesia (D9243) provided on April 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration.

You asked the Plan to pre-approve bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (List separately in addition to code for primary procedure) (20939). You say that delaying this surgery greatly affects the enrollee's daily life. The Plan denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of spinal fusion surgery have not been demonstrated in the peer-reviewed literature.

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 bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (List separately in addition to code for primary procedure) (20939). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspiration remains experimental in cases of spinal fusion. More research is needed to show safety and efficacy of the bone marrow aspiration. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (List separately in addition to code for primary procedure) (20939) have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) and the drug testing (80305, G0483) on December 14, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit (99214) and the drug testing (80305, G0483). You say that the enrollee was mistakenly called in for treatment without a referral. You say the provider performed the services assuming a valid referral was on file. The Plan denied your request. The Plan says originally the claim was incorrectly processed, but the claim was adjusted, and no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit (99214) and the drug testing (80305, G0483) provided on December 14, 2020 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a single-photon emission computerized tomography (SPECT) nuclear medicine test (78452) provided on April 21, 2021.
You asked the Plan to waive the copayment for SPECT nuclear medicine test. You say that the copayment applied is not accurate. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 $350 copayment for nuclear medicine services as an outpatient hospital visit.
You have been asked to pay a $350 copayment for a SPECT nuclear medicine test. The records show that this service was provided in an outpatient hospital setting. The EOC confirms $350 is the required copayment for this service when rendered in an outpatient hospital. A SPECT nuclear medicine test falls within the outpatient hospital services 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 single-photon emission computerized tomography (SPECT) nuclear medicine test (78452) provided on April 21, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the remote pacemaker evaluation performed by your cardiologist on November 26, 2020.
You asked the Plan to waive the copayment for the remote pacemaker evaluation by your cardiologist. You say that you do not believe it is fair to have to pay a copayment for this service because the doctor doesn't call you, they just see a computer. The Plan denied your request. The Plan says you were charged this copayment correctly.
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 $30 copayment for non-radiological diagnostic services.
You have been asked to pay a $30 copayment for the remote pacemaker evaluation by your cardiologist. This service falls within the non-radiological diagnostic services 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 the remote pacemaker evaluation performed by your cardiologist on November 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the power wheelchair accessory (E2310).
You asked the Plan to pay for the power wheelchair accessory. You say that the claim should be approved. The Plan denied your request. The Plan says they will overturn the request for a power wheelchair, but not the E2310 electrical connection device.
The Plan must follow Medicare rules. Medicare rules say that there must be demonstrated, documented need for the multiple functions to be controlled through the E2310 electrical interface, rather than the included switches. The documentation did not contain a need for the electrical connector. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the power wheelchair accessory have not been met. Therefore, we decided that the Plan does not have to pay for the power wheelchair accessory (E2310).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient admission for a total knee arthroplasty. 
 
You asked the Plan to pre-approve inpatient care. The Plan denied your request. The Plan says the enrollee will 
not require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.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 inpatient care. Our physician reviewer 
found that the enrollee has been diagnosed with left knee degenerative arthritis. She is scheduled for a planned 
knee surgery. The documentation provided does not show that the enrollee's necessary care will span two 
midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an inpatient admission for a total knee arthroplasty.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to hold you harmless for a lumbar laminectomy, facetectomy and foraminotomy (63047, 63048) performed on April 12, 2021.

You asked the Plan to hold you harmless for a lumbar laminectomy, facetectomy and foraminotomy. You say that the requested services were a medical necessity for the enrollee. The Plan denied your request. The Plan says that rules for payment have not been met because the requested services were not authorized prior to the date of service.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. 

You were referred for a lumbar laminectomy, facetectomy and foraminotomy by a contract provider. The file does not show that the Plan provided notice that a lumbar laminectomy, facetectomy and foraminotomy would not be covered. Under Medicare rules, this means a lumbar laminectomy, facetectomy and foraminotomy is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for a lumbar laminectomy, facetectomy and foraminotomy (63047, 63048) performed on April 12, 2021.

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 pre-approve the upper and lower partial denture (D5211 and D5212).
You asked the Plan to pre-approve the upper and lower partial denture (D5211 and D5211). You say that you were given an eviction notice due to a prolonged hospital stay and left your dentures. You say that you could not retrieve them, and it is hard for you to eat without your dentures. The Plan denied your request. The Plan says this service is only allowed one time in 5 calendar years.
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, your Plan also has a maximum benefit of one of D5110, D5211 or D5213 every 5 calendar years and one of D5120, D5212 or D5214 every 5 calendar years. The Plan paid for an upper and lower partial denture (D5213 and D5214) provided on September 30, 2019, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the upper and lower partial denture (D5211 and D5212).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion services represented by code 99601 provided on January 4, 2021.

You asked the Plan to pay for code 99601. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We looked at the file and Medicare rules. In this case, CPT code 99601 has a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, this service. Therefore, we decided that the Plan does not have to pay for the home infusion services represented by code 99601 provided on January 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the breast prosthesis provided on March 3, 2021 by an non-certified provider.
You asked the Plan to pay for the breast prosthesis. You say that the Plan said that these services would be covered. The Plan denied your request. The Plan says Nordstrom is not a certified network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the breast prosthesis provided on March 3, 2021 by an non-certified provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp for the enrollee.

You asked the Plan to pre-approve Aranesp. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no indication Retacrit would likely be less effective, and/or cause adverse effects for the member.

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 Aranesp. Our reviewer says that Aranesp is not medically reasonable and necessary for the enrollee. There was no indication Retacrit would likely be less effective, and/or cause adverse effects for the member. Both of these medications are in the same class and have not been shown to be significantly different in terms of benefits and risks to favor one over the other. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Aranesp. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular diagnostic testing (0037U) provided on September 22, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for molecular diagnostic testing. You say that the service performed was medically necessary and helps identify possible treatment options for the member based on the results. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network provider.
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. The records provided for review do not show that the services at issue were urgent or emergent. 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 molecular diagnostic testing (0037U) provided on September 22, 2020, by an out-of-network (OON) provider.
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 you need this care to get you back to your baseline. The Plan denied your request. The Plan says that records show you do not currently require complex daily nursing care or daily skilled rehabilitation therapy.
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 the acute inpatient hospital care provided September 12, 2020, to September 29, 2020.

You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was medically necessary The Plan denied your request. The Plan says there was a lack of medical records to determine medical necessity.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 acute inpatient hospital care. Our reviewer says that there was no documentation of hemodynamic instability or evidence of infection. The enrollee was admitted for placement. The documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided September 12, 2020, to September 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a rest home visit (99336) provided on April 20, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a rest home visit. You say that a prior authorization was not obtained since it is the nursing facilities responsibility to get an authorization. You also say it was medically necessary for the member to receive this treatment and you did not know the facility failed to get authorization. The Plan denied your request. The Plan says services were provided by an out-of-network provider without 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 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 a rest home visit (99336) provided on April 20, 2021, by an out-of-network (OON) provider.