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

We decided that the Plan does not have to pay forthe perfusionist services provided to the enrollee on November 15, 2019.You asked the Plan to pay forthe services provided. You say that the charges are for the perfusionist that set up and operated the heart-lung machine for the enrollee's surgery.The Plan denied your request. The Plan says payment for this service is the responsibility of the vendor.The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility for services furnished to a beneficiary.We looked at the file and Medicare rules.The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This service was provided via arrangement of the facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility.Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pay forthe perfusionist services provided to the enrollee on November 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral 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 there are an additional network specialists, as well as network tertiary level facilities 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 provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve removal of cyst at wrist for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no clear documentation of visual disturbance, and no documentation of other conservative treatment trials and failures.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 the surgery. Our reviewer says that the requested surgery is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee presents with a volar wrist ganglion cyst. She reports discomfort and she is bothered by its appearance. Clinical exam findings document a 1 x 1 x 0.5 cm volar cyst adjacent to the radial artery. Under consideration is a request for surgical excision of the wrist cyst. Current evidence based medical literature would support surgical excision based on the location of the cyst adjacent to the radial artery. Given the location of the cyst and subjective complaints, the request for removal of cyst at the wrist would be considered medically reasonable and 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 surgery have been met. Therefore, we decided that the Plan has to pre-approve removal of cyst at wrist for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on November 18, 2019 by an out of network (OON) provider.You asked the Plan to pay forphysician visit. You say that you are appealing.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and prior authorization was not 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 topay 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 forthe medical services provided on November 18, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered to the enrollee on August 20, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim is a duplicate.The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.We looked at the file and Medicare rules. The file shows that claim is a duplicate of a claim that was previously paid by the Plan. Based on this information, we decided that Medicare rulesfor coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered to the enrollee on August 20, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on November 20, 2019 by an out of network (OON) provider.
You asked the Plan to pay for psychotherapy services. You say that this patient will not see a different provider, it would be detrimental to this patient's mental health to have to find a different provider. The Plan denied your request. The Plan says there are in-network providers who can provide 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 psychotherapy services provided on November 20, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar/sacral facet injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your
request. The Plan says this request exceeds the Medicare limit of five sessions per year.
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 injection. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the standard of care is to repeat the radiofrequency ablation on the prior innervation, as the pain relief
lasted greater than six months; not repeat the entire diagnostic sequence. Therefore, the request is not medically
reasonable and 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 injection have not been met. Therefore, we decided that the Plan does not
have to pre-approve a lumbar/sacral facet injection for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-rays, implant placement, custom abutment and implant supported crown provided from April 5, 2019 through August 5, 2019.
You asked the Plan to pay for the x-rays, implant placement, custom abutment and implant supported crown. You say that you went through the office for the implants but the services were denied. The Plan denied your request. The Plan says dental services from an out-of-network provider are not covered benefits.
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 out-of-network items and services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the x-rays, implant placement, custom abutment and implant supported crown provided from April 5, 2019 through August 5, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve positron emission tomography (PET) scan services.
You asked the Plan to pre-approve the PET scan. You say that the records provided support the need for the requested PET scan. The Plan denied your request. The Plan says the requested PET scan is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically 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 the PET scan. Our reviewer says that the requested PET scan is not medically reasonable and necessary. Our physician reviewer found there is no evidence that the enrollee has, or is thought to have, a brain tumor. There is no evidence that the enrollee is to undergo an invasive procedure related to a brain tumor. 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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve positron emission tomography (PET) scan services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the perfusionist services
You asked the Plan to pay for the services provided. You say that the charges are for the perfusionist that set up and operated the heart-lung machine for the enrollee's surgery. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility.
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility for services furnished to a beneficiary. We looked at the file and Medicare rules. The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This service was provided via arrangement of the facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the perfusionist services
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CYP panel rendered  on September 23, 2019.
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 were not billed correctly and are non-covered.
The Plan must follow Medicare rules. The rules say that all CYP panels should be billed with 81479 and are non-covered. The testing at issue is a CYP panel. The file shows that the testing was not billed with the required 81479 code. Furthermore, this testing is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the CYP panel rendered on September 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a standard wheelchair (K0001) and elevating leg rests (K0195).
You asked the Plan to pre-approve a standard wheelchair and elevating leg rests. You say that the items are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that a manual wheelchair and elevating leg rests are covered when specific criteria is met. 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 standard wheelchair and elevating leg rests. Our reviewer says that the items are not medically necessary. Our physician reviewer found clinical documentation is not supporting that you have mobility issues that meet the criteria for coverage. The requested items are 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 standard wheelchair and elevating leg rests have not been met. Therefore, we decided that the Plan does not have to pre-approve a standard wheelchair (K0001) and elevating leg rests (K0195).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the SNF services. You say that the enrollee is not ready to go home and she is not able to care for him at home. The Plan denied your request. The Plan says the enrollee does not meet the medical requirements for additional time in a SNF.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and had stable vital signs. The enrollee received physical therapy and occupational therapy in the SNF. By the dates in question, the enrollee was at a maximal assist level with functional mobility. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve emptying a gland on the eyelid for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says CPT 0207T (clear eyelid gland with heat) is a non-covered code.
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 procedure. Our reviewer says that the requested procedure not considered medically reasonable and necessary in this case. Our physician reviewer found meibomian gland dysfunction is a chronic condition affecting the eyelid glands that produce meibum, the lipid layer that covers the tears. There are many treatments for this condition, including warm compresses, lid massage, topical antibiotic and anti-inflammation drops, ointments (Azasite, steroids, Restasis), hypochlorous acid spray, oral anti-inflammatory agents (omega-3 fatty acids, doxycycline), and mechanical/thermal expression of meibomian glands (lipiflow/thermaflow). Currently, the enrollee has not exhausted all treatments listed and thermaflow/lipiflow are not considered 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 the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve emptying a gland on the eyelid for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the perfusionist services
You asked the Plan to pay for the services provided. You say that the charges are for the set up and operation of
the heart-lung machine for the enrollee's surgery. The Plan denied your request. The Plan says payment for this
service is the responsibility of the facility.
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other
than the facility for services furnished to a beneficiary.
We looked at the file and Medicare rules. The facility must furnish all necessary covered services to the
beneficiary either directly or under arrangements made with outside providers. This service was provided via
arrangement of the facility. Payment for this service would have been included under the facility claim.
Payment to you for this service is the responsibility of the facility. Based on this information, we decided that
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for
the perfusionist services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) provided on May 13, 2019.
You asked the Plan to pay for the office visit. You say that you are requesting a reconsideration of the Plan's denial as the care provided was necessary for the enrollee to be able to continue a normal quality of life without pain. The Plan denied your request. The Plan says that this service is not a covered benefit under the enrollee's contractual policy.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit (99203) provided on May 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist visits provided on October 30, 2019 and November 8, 2019.
You asked the Plan to waive the copayments for specialist visits. You say that you were told that you would not owe copayments. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for specialist services. You received specialist services on October 30, 2019. Therefore, you are responsible to pay the $50 copayment. You received specialist services on November 8, 2019. Therefore, you are responsible to pay the $50 copayment. Therefore, the total amount you owe is: $100. You have been asked to pay the total copayment amount of $100 for specialist visits. Specialist 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 copayments for specialist visits provided on October 30, 2019 and November 8, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 4, 2019 to September 30, 2019 by an out of network (OON) provider.
You asked the Plan to pay for outpatient service. You say that the enrollee did not make you aware of the change to her insurance. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the enrollee self-directed for service.
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 medical services provided on September 4, 2019 to September 30, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that thePlan does not have to pay forthe medical services provided on November 18, 2019 by an out of network (OON) provider.You asked the Plan to pay foranesthesia service. You say that anesthesiologists do not obtain authorizations or referrals.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and prior approval was not 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 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 forthe medical services provided on November 18, 2019 by an out of network (OON) provider.