Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy evaluation provided on January 13, 2021.
You asked the Plan to waive the copayment for the physical therapy evaluation. You say that the physical therapy evaluation was ordered by your surgeon and you were referred to pain management. The Plan denied your request. The Plan says the copayment applied 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 $40 copayment for physical therapy at an in-network outpatient hospital.
You have been asked to pay a $40 copayment for the physical therapy evaluation. The physical therapy
evaluation falls within the "Outpatient rehabilitation 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 physical therapy evaluation provided on January 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for molecular pathology provided on February 17, 2021.

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 that when a laboratory assays two or more genes in a patient in parallel, those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one procedure code must be submitted for the panel.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the claim should have been billed under one procedure code as opposed to a code for each assay. A corrected claim is required for payment. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for molecular pathology provided to the enrollee on February 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Venofer.
You asked the Plan to pre-approve Venofer. You say that Venofer is necessary for the enrollee's condition. The Plan denied your request. The Plan says there is no intolerance or inadequate response to oral iron.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Venofer. Our physician reviewer found that the enrollee has a past history of iron deficiency anemia secondary to malabsorption. It is unclear how the diagnosis of iron deficiency anemia was made. There is no substantiation of iron deficiency anemia. There is no documentation of intolerance or inadequate response to oral iron. The review has determined that the documentation does not support that Venofer is medically reasonable or necessary for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Venofer have not been met. Therefore, we decided that the Plan does not have to pre-approve Venofer
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee's therapy needs are not precluded in an alternate level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 IRF care. Our physician reviewer found that the enrollee was admitted to the acute care hospital for a urinary tract infection and acute kidney injury. Her medical problems are stable. There are no complex nursing needs. She does not require treatment by multiple therapies, including either physical or occupational therapy, in an intensive rehabilitation therapy program.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pattern electroretinography (PERG) testing.

You asked the Plan to pre-approve the PERG testing. You say that these services are necessary every year since you are diabetic. The Plan denied your request. The Plan says this testing is considered a non-standard test and falls under the class of experimental and/or unproven services.

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 PERG testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has a history of diabetes and glaucoma. The record does not indicate that the enrollee has signs of diabetic retinopathy. The provided record indicates the enrollee is being treated for glaucoma. The provided record does not support the medical necessity or reasonableness, as defined by Medicare rules, of the requested service for the enrollee's specific condition. The requested test has not been established to be safe and effective, as defined by Medicare rules, for the enrollee's condition. The elements of the coverage criteria are not satisfied.

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 PERG testing have not been met. Therefore, we decided that the Plan does not have to pre-approve pattern electroretinography (PERG) testing.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health care supervision (G0181) provided on
February 28, 2021 by an OON provider.
You asked the Plan to pay for the home health care supervision. You say that you would like this claim to be
reprocessed because it is medically necessary to establish an effective treatment plan for the good of the
enrollee. The Plan denied your request. The Plan says these services were rendered by a non-contracted
provider. The Plan also says that the services were not referred by a network provider or rendered in a
participating facility.
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 home health care supervision (G0181)
provided on February 28, 2021 by an OON provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee can be treated at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee does not require treatment by multiple therapies and an intensive
rehabilitation therapy program. While the documentation does support a need for physical or occupational
therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive
rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for psychotherapy visits provided on April 9, 2021 and April 16, 2021.
You asked the Plan to waive the deductible the psychotherapy visits. You say that the visits are covered services, and your cost share should be less. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
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 $203 combined deductible that applies towards out-of-network psychotherapy visits.
The psychotherapy visits you asked the Plan to waive the deductible falls within the "Outpatient mental health care" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $203 combined deductible that applies towards out-of-network mental health services. This cost sharing is a contractual obligation that had not been met at the time the psychotherapy visits were received on April 9, 2021 to April 16, 2021. Therefore, we decided that the Plan does not have to waive the deductible for psychotherapy visits provided on April 9, 2021 and April 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction provided on March 15, 2021.

You asked the Plan to pay for the extraction. You say that you were referred by your dentist. The Plan denied your request. The Plan says this provider opted out of Medicare and we cannot pay this claim.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the extraction provided on March 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve monitored anesthesia.

You asked the Plan to pre-approve anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); prone
position (01992). You say that the enrollee needs injections for chronic low back pain. The Plan denied your request. The Plan says there is no statement in the records concerning medical necessity for intravenous sedation for this minimally invasive procedure.

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 anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); prone position (01992). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that monitored anesthesia care is not routinely necessary for facet joint injections. There is no statement in the records concerning the medical necessity for intravenous sedation/MAC. The requested MAC for is not considered reasonable or medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); prone position (01992) have not been met. Therefore, we decided that the Plan does not have to pre-approve monitored anesthesia.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical knee arthroscopy (29881).
You asked the Plan to pre-approve a surgical knee arthroscopy. You say that this is medically necessary. The Plan denied your request. The Plan says this is not indicated for the enrollee.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a surgical knee arthroscopy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the submitted medical records do not include detailed documentation regarding trial and failure of recent conservative care measures as injection types and dates were not provided. Furthermore, x-rays are noted to show severe degenerative changes with moderate/severe joint space narrowing, spurring, and osteophyte formation. There is limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and safe treatment for the overwhelmingly osteoarthritic pathology. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception.
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 surgical knee arthroscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve a surgical knee arthroscopy (29881).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 genetic testing provided on February 10, 2021.

You asked the Plan to pay for genetic testing. You say that this testing was ordered by the enrollee's treating physician in order to assist in determining the optimal treatment options for the enrollee. The Plan denied your request. The Plan says this testing was not billed with the appropriate coding and should be billed under a single panel code of 81479.

The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be billed with procedure code 81479. 

We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 genetic testing provided on February 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two problem focused limited oral evaluations provided on May 4, 2021, and May 7, 2021.
You asked the Plan to pay for the problem focused limited oral evaluations. You say that this problem needed to be taken care of immediately. The Plan denied your request. The Plan says this service is not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. The record also shows that you signed a consent for treatment that says you agreed to be responsible for all services rendered on your behalf. Therefore, we decided that the Plan does not have to pay for the two problem focused limited oral evaluations provided on May 4, 2021, and May 7,
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient therapy provided from March 15, 2021, through March 18, 2021.
You asked the Plan to waive the copayment for outpatient therapy. You say that he was placed in the dementia unit and was not supervised as necessary. You say that the Plan should pay for the unfortunate stay. The Plan denied your request. The Plan says the copayments applied 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $40 copayment for Medicare-covered in-network outpatient rehabilitation services.
The enrollee has been asked to pay a $40 copayment for each outpatient therapy visit. The total amount owed is $160 ($40/visit x 4 visits = $160). Outpatient therapy falls within the "Outpatient rehabilitation services" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient therapy provided from March 15, 2021, through March 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230) and prophylaxis - adult (D1110) provided February 11, 2021, and the resin-based composite - two surfaces, anterior (D2331) provided March 2, 2021.
You asked the Plan to pay for the dental exam, intraoral x-rays, dental cleaning and fillings. You say that you had planned to get the dental work done in 2020 when you had dental coverage, but you were unable to have the dental work completed due to the pandemic. You received these service in 2021 but forgot to purchase supplemental dental benefits. You would like the Plan to help cover the services. The Plan denied your request. The Plan says you did not have supplemental dental coverage at the time the services were provided and therefore they are not covered.
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 periodic oral evaluation - established patient (D0120), intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230) and prophylaxis - adult (D1110) provided February 11, 2021, and the resin-based composite - two surfaces, anterior (D2331) provided March 2, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the coronavirus testing (U0004) provided on August 24, 2020.
You asked the Plan to pay for the laboratory testing. You say that the services were 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 coronavirus testing (U0004) provided on August 24,
2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergency ambulance services (A0426, A0425) provided on March 15, 2021.
You asked the Plan to pay for non-emergency ambulance services. You say that you should not have to pay for these services. The Plan denied your request. The Plan says the cost share was applied correctly.
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 $600 deductible you must meet before the Plan pays for covered services. The Plan contract also says that once you meet your deductible there is a 20% coinsurance for ambulance services. The item or service you asked the Plan to pay for falls within the benefit category ambulance services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $600 deductible you must meet before the Plan pays for covered services. The Plan contract also says that once you meet your deductible there is a 20% coinsurance for ambulance services. This cost sharing is a contractual obligation that had not been met at the time non-emergency ambulance services was received on March 15, 2021. Therefore, we decided that the Plan does not have to pay for non-emergency ambulance services (A0426, A0425) provided on March 15, 2021.