Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more forthe cone beam CT capture (D0364), pulp vitality tests (D0460) and abscess drainage (D7510) provided on March 5, 2020.You asked the Plan to pay more forthe cone beam CT capture (D0364), pulp vitality tests (D0460) and abscess drainage (D7510). You say that the abscess was drained to relieve the pain, discomfort and swelling. You say that the dentist tried to save the tooth so the expenses should be covered.The Plan denied your request. The Plan says the claim processed correctly.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 Plan is only obligated to pay their share ofyourcovered services.ServiceCovered Service?Allowed AmountCoinsurancePlan PaidMember LiabilityCone Beam CT CaptureNo$350N/A$0$350Pulp Vitality TestsNo$165.85N/A$0$165.85Abscess DrainageYes$37050%$185$185TOTAL$700.85 Therefore, we decided that the Plan does not have to pay more forthe cone beam CT capture (D0364), pulp vitality tests (D0460) and abscess drainage (D7510) provided on March 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient psychiatric facility for the enrollee.You asked the Planto pre-approvethe admission. You say that this is medically necessary.The Plandenied your request. The Plansaysthere are other services that may be available as part of the mental health benefit.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 the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found it is 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 no auditory, visual hallucinations or delusions. She was described as being cooperative. 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.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 admission have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to an inpatient psychiatric facility for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered by an out-of-network provider on
March 6, 2020.
You asked the Plan to pay for these services. You say that this is the only provider that could assist you. The
Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior
authorization.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services,
plans are not required to make payments for any services received by enrollees that are not provided directly by
the Plan or through arrangements made by the Plan.
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not
have to pay for the services rendered by an out-of-network provider on March 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray (71046) provided on January 14, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the chest x-ray. You say that the services were medically necessary and should be covered. The Plan denied your request. The Plan says the services were not pre-authorized or emergent. There were network providers 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 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 chest x-ray (71046) provided on January 14, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 15 office consultation and treatment visits to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the out of network consultation and treatment visits. You say that the services being requested are medically necessary prior to the enrollee proceeding with the invasive procedure of a right heart catheterization. The Plan denied your request. The Plan says there are pulmonologist who are in network and who are experienced with clinical issues like these. The Plan says that the enrollee's needs can be met within the health plan network and that the criteria for an outside referral have not been met.
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 15 office consultation and treatment visits to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction and two bone replacement grafts provided on
April 24, 2019 and February 17, 2020.
You asked the Plan to pay for the extraction and bone replacement grafts. You say that you were having pain in
your front tooth and your dentist told you that you needed oral surgery. You also say that these services were
medically necessary, due to an infection you had in your mouth. The Plan denied your request. The Plan says
these services were performed due to infections, and were not performed as a result of an accidental injury.
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
extraction and two bone replacement grafts provided on April 24, 2019 and February 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe resin-based composites (codes D2332 and D2392) and periodontal maintenance (D4910) provided on January 16, 2020 by an OON provider.You asked the Plan to pay forthe resin-based composites and periodontal maintenance. You say that this provider has been your dentist for 8 years, and is a member of the dental plan.The Plan denied your request. The Plan says the treating provider is OON. The Plan also says that services done by an OON dentist are 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 covered when they are received OON.Therefore, we decided that the Plan does not have to pay forthe resin-based composites (codes D2332 and D2392) and periodontal maintenance (D4910) provided on January 16, 2020 by an OON provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic ultrasound rendered on October 8, 2019.
You asked the Plan to waive the copayment for these services. You say that you did not have a choice but to get an ultrasound. The Plan denied your request. The Plan says the copayment was 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 $50 copayment for diagnostic radiology.
Review of the file shows that you received a diagnostic ultrasound on October 8, 2019. You have been asked to pay a $50 copayment for these services. These services fall within the diagnostic radiology 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 diagnostic ultrasound rendered on October 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says not having a portable oxygen concentrator puts the enrollee at an unnecessary risk for hypoxia.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The file shows that portable oxygen tanks have been ordered for the enrollee. The portable tanks serve the same purpose as the requested portable oxygen concentrator. The documentation in the case file does not include a physician order or certificate of medical necessity for the requested concentrator.Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services (G0151) provided to the enrollee
from November 29, 2019.
You asked the Plan to pay for home health services. You say that this was billed correctly. The Plan denied
your request. The Plan says this was billed without a necessary Q code.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, this claim
was billed without a Q code to indicate the place of service. Therefore, we decided that the Plan does not have
to pay for the home health services (G0151) provided to the enrollee from November 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services providedon January 16, 2020.You asked the Plan to pay for the physician's services.The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the servicesat 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 physician's servicesprovided on January 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

e decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on February 22, 2020.You asked the Plan to pay forthe orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on February 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on July 16, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan failed to make a decision within the required time frame.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on July 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the upper partial denture (D5213) provided on January 29, 2020.You asked the Plan to pay for the upper partial denture (D5213). You say that the service was approved with an expiration date of June 20, 2020. You say that payment shouldn't have been denied.The Plan denied your request. The Plan says the service is 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.The pre-authorization shows that you must be eligible for benefits when the services are incurred. Dentures were no longer a covered benefit in the 2020 plan year.Therefore, we decided that the Plan does not have to pay for the upper partial denture (D5213) provided on January 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on September 19, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered on September 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the
enrollee on July 29, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the records do not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of HCPCS code G0483 is "Drug test(s), definitive, utilizing (1)
drug identification methods able to identify individual drugs and distinguish between structural isomers (but
not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any
type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods
(e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all
samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or
drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations
and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22
or more drug class(es), including metabolite(s) if performed."
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 services. Our reviewer says that the
services at issue in this case were not supported by the medical records. Our physician reviewer found
Medicare rules state that if a lab bills laboratory services to Medicare, there must be a signed order from the
treating physician (or a progress note to support the intent to order) and documentation to support the medical
necessity of the ordered services. In this case, the case file contains only a signed Custom Toxicology Profile
order form. There are no medical records in the case file. There is no evidence that the UDT was tailored to the
enrollee's medical condition. The documentation does not support that the UDT was medically reasonable and
necessary for the enrollee in this case.
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 pay for drug testing services (HCPCS G0483) provided to the enrollee on July 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (SEWHO) (L3960) provided January 22, 2020.
You asked the Plan to pay for the orthosis. You say that please see the attached medical records which prove the medical necessity of the item and process the claim for payment. The Plan denied your request. The Plan says the services are not supported in the medical records received and the billed supply code cannot be verified.
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 pay for the orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation in the case file does not support that the requested shoulder/arm orthosis was medically reasonable and necessary for the enrollee in this case. The documentation does not support that the orthosis was medically reasonable and necessary for this enrollee, as there is no clinical documentation of a problem with the enrollee's shoulder, nor is there a physical examination of the shoulder. 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 orthosis have not been met. Therefore, we decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (SEWHO) (L3960) provided January 22, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approvethe SNF services. You say that the services are medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.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 does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. The enrollee does not require skilled nursing or therapy services on a daily basis.  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-approveskilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveAranesp for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary for anemia in chronic kidney disease.The Plandenied your request. The Plansaysstep therapy guidelines were not followed.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewerfound the plan requires a trial of Retacrit before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. Per the documentation, the Plan approved the drug Retacrit from 04/28/2020 to 10/28/2020. Retacrit is an equally effective erythropoetin stimulating agent. 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 drug have not been met.Therefore, we decided that the Plandoes not haveto pre-approveAranesp for the enrollee.