Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation 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 this is still being studied in clinical trials for efficacy in the treatment of knee pain. 
 
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 this is an experimental and investigational procedure that is the subject of several ongoing clinical trials. 
The enrollee is not enrolled in any trials, therefore, the request is considered 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular nerve radiofrequency ablation for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible charge for the services you received on 
February 12, 2020. 
 
You asked the Plan to waive the deductible. The Plan denied your request. The Plan says your deductible was 
not met. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1,000 deductible that you must pay out-of-pocket before the Plan 
will pay its share for covered medical services.  
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible that 
you must pay out-of-pocket before the Plan will pay its share for covered medical services. This cost sharing is 
a contractual obligation that had not been met at the time the services was received on February 12, 2020. 
Therefore, we decided that the Plan does not have to waive the deductible charge for the services you received 
on February 12, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90832) provided on February 20, 2020.
You asked the Plan to pay for the psychotherapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent or pre-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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service 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 psychotherapy services (90832) provided on February 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on January 13, 2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one unit of CPT 81479 and the appropriate DEX Z-Code.  
 
We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-Code. 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 pay for the Guardant360 testing provided on January 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an evaluation (D0150) and tooth extraction (D7210) to 
be performed by an Oral Surgeon. 
 
You asked the Plan to pre-approve an evaluation and tooth extraction to be performed by an Oral Surgeon. You 
say that the services are necessary. The Plan denied your request. The Plan says based on the documentation 
provided, coverage criteria has not been met. 
 
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 covered 
services when performed by a participating general dentist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of an evaluation and tooth extraction to be performed by an Oral Surgeon have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an evaluation (D0150) and tooth extraction 
(D7210) to be performed by an Oral Surgeon.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oxycodone extended-release tablets. You asked the Plan to pre-approve self-administered drugs. You say that this is a lifelong medication for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits. 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 oxycodone extended-release tablets. Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for fixed-wing air ambulance services provided January 29,
2020.
You asked the Plan to pay for the air ambulance services. You say that the air ambulances services were
emergent and should be covered. The Plan denied your request. The Plan says the member's worldwide
emergency benefit was exhausted at the time the air ambulance service was received.
The Plan must follow Medicare rules. Medicare rules say that health plans must pay for a medical service or
item if regular Medicare would pay for it. Medicare generally does not cover services performed outside the
United States.
We looked at the file and Medicare rules. While the plan does provide a $10,000 annual benefit for emergency
services provided worldwide, at the time of the air ambulance transport the enrollee had already exhausted the
$10,000 benefit on hospital inpatient services provided in another country. Based on this information, we decided
that Medicare rules for coverage of the air ambulance services have not been met. Therefore, we decided that
the Plan does not have to pay for fixed-wing air ambulance services provided January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic manipulative treatment (98941) to be rendered by the out of network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that chiropractic care is medically necessary for the enrollee. The Plan denied your request. The Plan says network providers are available to provide the chiropractic care requested. A referral for services with the out of network provider was not provided by the enrollee's primary care physician (PCP).  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that enrollees must get a referral from their PCP prior to getting care from out-of-network providers via their Point of Service benefit. A referral or prior authorization is never required for emergency care, urgently needed care when network providers are unavailable, and dialysis for members with ERSD who are temporarily out of the service area.  
 
The requested provider in this case is not a network provider with the Plan. The contract with the Plan says that enrollees must get a referral from their PCP prior to getting care from out-of-network providers via their Point of Service benefit. The Plan says a referral was not provided by the enrollee's primary care physician for chiropractic services with the out of network provider. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve chiropractic manipulative treatment (98941) to be rendered by the out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics (L3000) provided to the enrollee on February
14, 2020.
You asked the Plan to pay for foot orthotics. You say that that procedure code L3000 is covered under
Medicare guidelines for conditions like diagnosis code M72.2- plantar fascial fibromatosis. The Plan denied
your request. The Plan says based on Medicare guidelines, clearly state that coverage for foot orthotics is
limited to those with diabetic foot disease or for part of a leg brace. The Plan states the medical records and
diagnosis code only support (M72.2 - Plantar Fasciitis) and there was no documentation showing diabetes.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace.
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pay for foot orthotics
(L3000) provided to the enrollee on February 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the resin-based composite provided on February 18, 
2020. 
 
You asked the Plan to pay more for the resin-based composite. You say that you were told you were 
responsible for $82,50, but then received a document saying the request was denied. The Plan denied your 
request. The Plan says you are responsible for the difference between the allowed amounts. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the contract clearly states that you are 
responsible for a 50% coinsurance for silver fillings and white fillings. The record shows that you received a 
resin-based composite on February 18, 2020 and the 50% coinsurance applies, per your 2020 EOC. The 
contract clearly states that you will be responsible for up to the contracted fee. Therefore, we decided that the 
Plan does not have to pay more for the resin-based composite provided on February 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care beyond July 27, 2020. 
 
You asked the Plan to pre-approve ongoing inpatient care. You say that it would be beneficial for the enrollee to remain inpatient at this time. The Plan denied your request. The Plan says the enrollee is stable and can be managed 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 ongoing inpatient care. Our reviewer says that the requested continuation of inpatient psychiatric care is not reasonable and necessary. Our physician reviewer found this 74-year-old female was admitted to the acute inpatient psychiatric hospitalization on July 8, 2020 with Unspecified Dementia with Behavioral Disturbance. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The patient was compliant with treatment while not showing any acute threats to safety. 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 she did not have dangerousness to self or others but was compliant with her treatment. The health plan's denial of continued inpatient psychiatric services is appropriate. This enrollee did not appear to require inpatient mental health treatment beyond the date in question as she was not a danger to herself or others and did not have any auditory or visual hallucinations while being cooperative with treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis beyond the date in question. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ongoing inpatient care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care beyond July 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses purchased March 6, 2020.
You asked the Plan to pay for the eyeglasses. You say that you are appealing for reconsideration of the denied
charges. The Plan denied your request. The Plan says you exhausted your benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case.
We looked at the file and the Plan's rules. The plan covered eyeglasses for you on May 24, 2019. You are
eligible for another pair of eyeglasses after January 01, 2021. Your EOC says that standard lenses and frames,
limited to one (1) pair of lenses and frames every two (2) years. After Plan paid benefits for eye glasses (lenses
and frames) or contact lenses, you are responsible. Therefore, we decided that the Plan does not have to pay for
the eyeglasses purchased March 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided from January 3,
2020 to March 9, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.
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 service 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 out of network physician services provided from January 3, 2020 to March 9,
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray, prophylaxis, topical application of
fluoride varnish, periodic oral evaluation, and oral hygiene instructions provided on February 6, 2020 by an
OON provider.
You asked the Plan to pay for the panoramic x-ray, prophylaxis, topical application of fluoride varnish,
periodic oral evaluation, and oral hygiene instructions. You say that you were under the impression that you
would receive coverage for routine dental exams even though your dentist is OON. The Plan denied your
request. The Plan says the treating provider is not a contracted provider with the Plan. The Plan also says that
no benefits are available for procedures performed by OON providers or outside of the providers contracted
period.
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
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the
panoramic x-ray, prophylaxis, topical application of fluoride varnish, periodic oral evaluation, and oral hygiene
instructions provided on February 6, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for office visits provided from June 3, 2019 to 
December 11, 2019. 
 
You asked the Plan to waive the coinsurance for office visits. You say that you were told that you would not 
have cost-sharing with this Plan. The Plan denied your request. The Plan says the cost-sharing amounts you are 
being charged are 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 20% 
coinsurance for primary care office visits. The allowed amounts of these claims total $192.65, resulting in a 
total coinsurance obligation of $38.53. 
 
You have been asked to pay 20% coinsurance for office visits. Office visits fall within the 
Physician/Practitioner Services, Including Doctor's Office Visits 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 for office visits provided from June 3, 2019 to December 11, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
March 31, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 has network providers available 
who can provide the services at issue in this appeal. The Plan did not pre-approve the service 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 out of network physician services provided to the enrollee on March 31, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric evaluation (90792) provided on November 26, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for an OON psychiatric evaluation. You say that this was a medically necessary service provided in good faith. The Plan denied your request. The Plan says this service was 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 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 the psychiatric evaluation (90792) provided on November 26, 2019 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the colonoscopy provided on February 17, 
2020. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that you had noticed blood in your 
stool and scheduled a routine colonoscopy. You say you do not believe the colonoscopy should have been 
coded as diagnostic. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing 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 $300 
copayment for each in-network Medicare-covered outpatient surgery or procedure at an outpatient hospital 
facility or ambulatory surgical center.  
 
You have been asked to pay a $300 copayment for the colonoscopy. The colonoscopy falls within the 
?Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers? benefit category. The record shows you had blood in your stool which makes the colonoscopy 
diagnostic in nature. 
 
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 colonoscopy provided on February 17, 2020.