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

We decided that the Plan does not have to pay for the first intraoral periapical x-ray, endodontic therapy, and
core buildup, including any pins when required provided on February 13, 2020 by an OON provider.
You asked the Plan to pay for the first intraoral periapical x-ray, endodontic therapy, and core buildup. You say
that this provider was on a list of in-network providers that you received from the Plan. You also say that you
confirmed with a Plan representative that this provider was in-network. The Plan denied your request. The Plan
says the treating provider is OON with your plan. 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 for the first
intraoral periapical x-ray, endodontic therapy, and core buildup, including any pins when required provided on
February 13, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on November 26, 2019.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says Comprehensive Genomic Profile (CGP) testing NEXT-Generation requires use of CPT 81479.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on November 26, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient care provided from November 1, 2019 to November 9, 2019.
You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says the enrollee was stable for transfer prior to admission.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.
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 inpatient care. Our reviewer says that the requested inpatient care was considered post-stabilization care. Our physician reviewer found that the enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring to a plan facility for admission after the emergency room evaluation on November 1, 2019. There was no documentation provided necessitating post-stabilization care services from November 1, 2019 to November 9, 2019 at the out-of-network facility. 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 inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient care provided from November 1, 2019 to November 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cytopathology services (CPT 88112 and CPT 88121) provided to the enrollee on December 4, 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 that there were two interpretations of the services.
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 the denied codes is: CPT 88112: Cytopathology, selective cellular enhancement technique with interpretation) CPT 88121: Cytopathology, in situ hybridization (eg, FISH), urinary tract specimen with morphometric analysis, 3-5 molecular probes, each specimen We asked our coding 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 coding reviewer found the provider was reimbursed for 88112 and 88121 on December 12, 2019. For 88112 and 88121, date of service December 4, 2019 does not meet the criteria. The pathology report submitted does not include two interpretations, and therefore would be considered a duplicate claim.
We looked at this coder'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 cytopathology services (CPT 88112 and CPT 88121) provided to the enrollee on December 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bed side rails (E0305) DME delivery, set up, and dispensing (A9901) provided October 9, 2019.
You asked the Plan to pay for the bed rails and delivery and set up. You say that the enrollee is in an assisted living facility. This is a necessity since the normal bed rails are illegal in the facility because people have gotten caught and died. The Plan denied your request. The Plan says this service is a convenience item and is not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for bed side rails (E0305) DME delivery, set up, and dispensing (A9901) provided October 9, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveGelsyn-3 injections (J7328).You asked the Plan to pre-approve the Gelsyn-3. You say that the enrollee has tried and failed the preferred medication in September 2019.The Plan denied your request. The Plan says the information submitted does not meet the Plan's medical necessity guidelines for coverage.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 Gelsyn-3. Our reviewer says that Gelsyn-3 does not meet the Plan's coverage criteria. Our physician reviewer found the Plan requires that other forms of hyaluronic acid injections be used (Orthovisc, Monovisc). There is no evidence that the enrollee is allergic to or intolerant of these other forms of hyaluronic acid. Our reviewer found that while the enrollee has failed treatment with Orthovisc, there is no evidence that the enrollee has tried and not responded to Monovisc. There is no documentation as to why Monovisc would not be expected to be safe and effective for the enrollee. Our physician reviewer also found that the requested Gelsyn is not shown to be currently medically necessary and reasonable. 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 Gelsyn-3 have not been met.Therefore, we decided that the Plan does not have to pre-approveGelsyn-3 injections (J7328).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intravitreal injection of a pharmacologic agent (67028) aflibercept injection (J0178) medical examination and evaluation (92012) and vision exam (92134) provided March 3, 2020 to April 21, 2020
You asked the Plan to pay for the vision services. You say that you believes that this provider is in-network and you should only be responsible for $45 copay. The Plan denied your request. The Plan says the $3000 point of service (POS) benefit has been exhausted.
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan contract says that enrollees must pay 30% coinsurance for out of network (POS). The plan will reimburse a maximum of $3000 for out of network (POS). There is a POS plan coverage limit. Once this limit is reached, you are responsible for 100% of the cost of out of network services. for vision care. You have been asked to pay $9595. There is a POS plan coverage limit. Once this limit is reached, you are responsible for 100% of the cost of out of network services. The vision services fall within the vision care 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 pay for intravitreal injection of a pharmacologic agent (67028) aflibercept injection (J0178) medical examination and evaluation (92012) and vision exam (92134) provided March 3, 2020 to April 21, 2020
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee on December 2, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The contract with the Plan also states specifically that home health services require prior authorization. The provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee on December 2, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device.
You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that Percutaneous image-guided lumbar decompression for lumbar spinal stenosis is only covered for enrollees that are enrolled in a clinical study. We looked at the file and Medicare rules. Review of the file does not support that the enrollee is enrolled in a clinical study. Based on this information, we decided that Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction device have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvesurgical placement of implant body and anesthesia services.You asked the Plan to pre-approvesurgical placement of implant body and anesthesia services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested 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-approvesurgical placement of implant body and anesthesia services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on October 22,
2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the
Plan does not have to pay for physician services provided to the enrollee on October 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for x-ray of the chest provided to the enrollee on December 9, 2019.You asked the Plan to pay for the x-ray. You say that this should be paid for.The Plan denied your request. The Plan says chest radiography should not be used for lung cancer, as it does not reduce mortality.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 code 71045 is "Radiologic examination, chest; single view."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 x-ray. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found a single-view chest X-ray as a screening tool has not been shown to decrease lung cancer.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 x-ray have not been met.Therefore, we decided that the Plan does not have to pay for x-ray of the chest provided to the enrollee on December 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair and battery.
You asked the Plan to pre-approve a power wheelchair and battery. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 power wheelchair and battery. Our reviewer says that the documentation does not support that the requested power wheelchair is medically reasonable or necessary. Our physician reviewer found you have diagnoses of COPD and pulmonary fibrosis. You use home oxygen and have poor walking tolerance. While the documentation does support that you have COPD and pulmonary fibrosis that cause mobility related activities of daily living deficits, the documentation does not support that you have the inability to utilize a less device (lightweight manual wheelchair, standard manual wheelchair, or use of a walker, etc.) Therefore, you do not meet criteria for the requested device. 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 power wheelchair and battery have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and battery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient surgery provided by a participating provider on January 14, 2020 to February 18, 2020.
You asked the Plan to waive the copayment for outpatient surgery. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct deductible has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1,000 deductible for outpatient surgery/in-network. The item or service you asked the Plan to waive the copayment for falls within the benefit category outpatient surgery/in-network. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible for outpatient surgery/in-network. The total amount you are being asked to pay is $995.30. This cost sharing is a contractual obligation that had not been met at the time outpatient surgery was received on January 14, 2020 to February 18, 2020. Therefore, we decided that the Plan does not have to waive the copayment for outpatient surgery provided by a participating provider on January 14, 2020 to February 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 15, 2019 by an out of network (OON) provider.You asked the Plan to pay for the automatic blood pressure monitor (A4670). You say that you would like reconsideration because this is a covered benefit.The Plan denied your request. The Plan says the member does not have an out-of-network benefit for durable medical equipment and the automatic blood pressure monitor is available in-network.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 August 15, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested admission is not medically necessary.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 underwent lumbar surgery. The documentation does not support that the complexity of the enrollee's nursing, medical and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee appears to be medically stable, and the documentation does not support that the enrollee has complex medical issues that require acute rehab nursing care, or monitoring by an inpatient physical medicine and rehabilitation physician three times per week. While the documentation does support that the enrollee may benefit from further physical therapy and occupational therapy, the enrollee does not require 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the comprehensive eye exam (92014) refraction services (92015) and fundus photography (92250) provided February 18, 2020.
You asked the Plan to waive the copayment for the vision services. You say that this was a routine eye exam and you should not be responsible for the $35 copayment The Plan denied your request. The Plan says the claim was processed and 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 $35 copay per visit for Medicare covered exams to diagnose and treat disease of the eye. for vision care. You have been asked to pay $35 copay for the vision services. The vision services fall within the vision care 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 comprehensive eye exam (92014) refraction services (92015) and fundus photography (92250) provided February 18, 2020.