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

We decided that the Plan does not have to pre-approve positron emission tomography and computed tomography (PET/CT).
You asked the Plan to pre-approve the PET/CT scan. You say that your initial staging was completed with nuclear medicine bone scan and CT scans of the abdomen and pelvis in May of 2021, as well as a pelvic MRI in June of 2021. You say that the CT scan identified significant lymphadenopathy despite your low PSA and small primary tumor; thus, you are requesting this PET scan to complete your staging and determine a treatment plan. The Plan denied your request. The Plan says the requested imaging is not supported for the first staging of prostate cancer.
The Plan must follow Medicare rules. Medicare rules say that MACs may determine coverage within their respective jurisdictions for PET using radiopharmaceuticals for their FDA approved labeled indications for oncologic imaging. 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/CT scan. Our reviewer says that the criteria for coverage of the requested PET scan have not been met. Our physician reviewer found the enrollee has high risk prostate cancer with metastatic adenopathy in left hemipelvis. Our physician reviewer found that the PET being requested is using the radiopharmaceutical Ga 68 PSMA-11, which is a drug used for detection of specific cancer lesions in men with prostate cancer. The FDA approved label indications for use of
this oncologic imaging are for patients whose newly diagnosed cancer could be cured with the initial treatment, or who have been treated for prostate cancer but have high prostate-specific antigen (PSA) in their blood. High PSA in the blood of these patients is a suspicious sign that cancer is coming back or spreading. While the enrollee's prostate cancer is newly diagnosed, it has spread to the abdominal lymph nodes and is not considered potentially curable with initial treatment. 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/CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve positron emission tomography and computed tomography (PET/CT).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on February 11, 2021.
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 claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct Place of Service (POS) code. We looked at the file and Medicare rules. The file shows that the claim was billed with POS code 12 for home, which is inappropriate for an office visit. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the office visit rendered on February 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic consultation with a dentist/physician other than the requesting dentist/physician (D9310) provided on January 27, 2021.
You asked the Plan to pay for the consultation. You say that these services were necessary, and you were led to believe this provider was in-network as the office is listed on the Plan's provider directory. The Plan denied your request. The Plan says they are willing to make a one-time exception for some of the requested services due to a misunderstanding about the network status of the provider in question. However, the diagnostic consultation with a dentist other than the requesting dentist will remain denied, as this is not a covered service regardless of who provides the care.
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. Therefore, we decided that the Plan does not have to pay for the diagnostic consultation with a dentist/physician other than the requesting dentist/physician (D9310) provided on January 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on January 12, 2021 by an
OON provider.
You asked the Plan to pay for the prophylaxis. You say that you would like this service to be covered. The Plan
denied your request. The Plan says the total liability amount of $75.00 was applied correctly. The Plan also
says that the enrollee liability is a contractual obligation under the Plan and cannot be waived.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for the difference
between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided on January 12, 2021 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on April 29, 2020.

You asked the Plan to pay for the laboratory services. You say that you are appealing the claim with medical records for further claim processing. You say that the claim should be reprocessed. The Plan denied your request. The Plan says prior authorization was required but 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 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 laboratory services provided by an out-of-network provider on April 29, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve MRI of the pelvis for the enrollee.
You asked the Plan to pre-approve the MRI. You say that this si medically necessary. The Plan denied your request. The Plan says that this is a similar study to the CT scan that's already approved.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the requested MRI is medically reasonable and necessary. Our physician reviewer found certainly a CT of the abdomen and pelvis is indicated for the purpose of local and distant staging. MRI of the pelvis is usually done as the procedure of choice to determine the extent of endometrial myometrial invasion and involvement of the cervix and for that purpose the MRI of the pelvis based upon the limited information provided should be approved as well. 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 MRI have been met. Therefore, we decided that the Plan has to pre-approve MRI of the pelvis for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 1, 2020, by an
OON provider.
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 rendered 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. 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 laboratory services provided on April 1, 2020,
by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport (A0429) provided on January 15, 2021.
You asked the Plan to pay for the ambulance service, basic life support, emergency transport (A0429). The Plan denied your request. The Plan says ambulance transport to or from an outpatient office is not a Medicare covered benefit.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 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 the ambulance service, basic life support, emergency transport (A0429). Our reviewer says that the ambulance service, basic life support, emergency transport is not medically necessary. Our physician reviewer found that this enrollee does not meet criteria for utilization of ambulance services as he did not have any emergent medical issues for which he required
ambulance services. The reason stated for his use of ambulance services was that he did not have a ride and that is not medically appropriate. 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 ambulance service, basic life support, emergency transport (A0429) have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport (A0429) provided on January 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus Gene Panel rendered on November 17, 2020.
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 medically necessary.
The Plan must follow Medicare rules. Medicare rules say that molecular pathology is covered when specific criteria are 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has biopsy proven hepatocellular carcinoma. The diagnosis is unequivocally established. The criteria for coverage are not met and the testing was therefore not 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus Gene Panel rendered on November 17, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services provided on October 1, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan based their denial of payment on the incorrect place of service (POS) entered on the claim for payment. The Plan states the POS on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The Plan says the enrollees claim history/medical records indicate that the specimen was obtained in a non-residential Substance Abuse Treatment Facility and should be billed with POS 57. However, the Plan has provided no such claims or medical records to verify that the specimen was indeed collected in POS 57. The Plan has not provided enough information to substantiate their reasoning for the denial of payment. Therefore, we decided that the Plan has to pay for the laboratory services provided on October 1, 2020.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ambulance transportation (A0427,
A0425) and the emergency department visit (99284) on January 21, 2021.
You asked the Plan to waive the copayments for the ambulance transportation and emergency department visit.
You say that you and your husband were not consulted before 911 was called. The Plan denied your request.
The Plan says the correct cost share applied to the claim.
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 Ambulance Services and a $90 copayment for Emergency Care.
You have been asked to pay $390 in copayments for the ambulance transportation ($300) and emergency
department visit ($90). Ambulance Services require a $300 copayment per one way trip. Emergency Care
requires a $90 copayment. 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 the ambulance
transportation (A0427, A0425) and the emergency department visit (99284) on January 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the progressive lenses (S0581) and tint, photochromatic (V2744) provided December 10, 2020.

You asked the Plan to pay for the progressive and photochromatic tint lens upgrades. You say that you are not satisfied with the glasses and do not feel you should have to pay for them. The Plan denied your request. The Plan says coverage according to your benefits has been applied correctly.

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. The Plan does not cover lens upgrades. 

We looked at the file and the Plan's rules. Though the Plan offers vision benefits in excess of Medicare coverage, the requested lens upgrades are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the progressive lenses (S0581) and tint, photochromatic (V2744) provided December 10, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from November 26, 2020, to November 30, 2020.
You asked the Plan to pay for the SNF services provided from November 26, 2020, to November 30, 2020. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says there were no skilled services provided from November 26, 2020, to November 30, 2020.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services provided from November 26, 2020, to November 30, 2020 have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from November 26, 2020, to November 30, 2020.
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 IRF care is medically necessary. The Plan denied
your request. The Plan says rules for IRF care have not been met.

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 that the patient was admitted to an acute care hospital for a stroke. Medical
conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. The patient does require physical and occupational therapy but there is no
documented need for an intensive rehabilitation program. Medically necessary services can be provided in a
different level of care. In conclusion, 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: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services (99285, 62270) provided August
16, 2019.
You asked the Plan to pay for the emergency room services. You say that the services were medically
necessary. The Plan denied your request. The Plan says the claim was not filed timely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for the emergency room services was not filed until February 9, 2021. This
means that more than one calendar year from the date of service had passed before a claim was filed.
Therefore, we decided that the Plan does not have to pay for emergency room services (99285, 62270)
provided August 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a full set of dentures (D5110, D5120).
You asked the Plan to pre-approve dentures. You say that you cannot afford to pay for the requested
items/services. The Plan denied your request. The Plan says the requested items/services are not a covered
benefit.
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. Therefore, we decided that the Plan does not have to pre-approve a full
set of dentures (D5110, D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on January 13, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 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 physician services provided on January 13, 2021 by an out of network (OON) provider.