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

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the thorax, without contrast material (71250).
You asked the Plan to pre-approve this service. You say that this service is medically necessary. The Plan denied your request. The Plan says this service is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that a CT scan of the thorax is not medically necessary. Our physician reviewer found that there is no specific clinical rationale provided for the requested CT of the thorax. Chest Imaging may be supported for the evaluation of a suspected pulmonary embolism if one of the following is met: There is an abnormal D-dimer test.- There is a Wells Criteria score higher than four points.- The patient has a new onset of one risk factor or symptom demonstrating high clinical probability of a pulmonary embolism. The clinical information provided does not meet these criteria, therefore, the request is not indicated at this time. The review has determined that the CT Scan is not medically reasonable or 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 this service have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the thorax, without contrast material (71250).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the skilled nursing facility services. You say that the SNF 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 in the Medicare rules section 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 skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the documentation supports that the enrollee requires skilled therapy services to safely and effectively provide medically necessary and reasonable treatment. However, the enrollee can remain in the current Inpatient Rehabilitation Facility until he is able to be safely discharged to the community. 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 skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neurology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve OON services. You say that the clinic is designed for those at risk for Alzheimer's disease. The Plan denied your request. The Plan says there are in-network neurology specialists available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve neurology services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network hematology/oncology
specialist.
You asked the Plan to pre-approve these services. You say that you do not want to go to multiple doctors. The
Plan denied your request. The Plan says the services are available from network providers.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a referral to an out-of-network hematology/oncology specialist.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the genicular nerve radiofrequency ablation procedure (64624) provided on October 26, 2020

You asked the Plan to pay for the genicular nerve radiofrequency ablation procedure. You say that the genicular nerve radiofrequency ablation procedure (64624) provided on October 26, 2020 was medically necessary. The Plan denied your request. The Plan says the genicular nerve radiofrequency ablation procedure (64624) provided on October 26, 2020 was not medically necessary.

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 genicular nerve radiofrequency ablation procedure. Our reviewer says that the genicular nerve radiofrequency ablation procedure (64624) provided on October 26, 2020 was not medically necessary. Our physician reviewer found genicular nerve ablation remains experimental for the treatment of knee pain. More research is needed to show safety and efficacy of the procedure. The provided genicular nerve ablation on October 26, 2020 was not medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the genicular nerve radiofrequency ablation procedure have not been met. Therefore, we decided that the Plan does not have to pay for the genicular nerve radiofrequency ablation procedure (64624) provided on October 26, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an interspinous spacer device (22870, 22869).

You asked the Plan to waive the copayment for the interspinous spacer device. You say that the spacer placement is medically necessary. The Plan denied your request. The Plan says the device is investigational and is not covered.

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 waive the copayment for the interspinous spacer device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found interspinous spacer devices remain experimental. More research is needed to show safety and efficacy of interspinous spacer devices. 

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 interspinous spacer device have not been met. Therefore, we decided that the Plan does not have to waive the copayment for an interspinous spacer device (22870, 22869).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer device placement (22869).
You asked the Plan to pre-approve the interspinous spacer device. You say that the interspinous spacer placement is medically necessary. The Plan denied your request. The Plan says this device is investigational and is not covered.
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 interspinous spacer device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the 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 the interspinous spacer device have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer device placement (22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventive procedure (D1999) or provide additional reimbursement for the comprehensive oral evaluation (D0150), and the prophylaxis (D1110) received December 10, 2020 from the out-of-network provider.
You asked the Plan to pay for the dental services. You say that you disagree with how much you have been charged. The Plan denied your request. The Plan says the correct cost share amount applied to the claim.
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 or in excess of what is covered under this benefit. The Plan does not provide coverage for D1999.
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 50% coinsurance for oral evaluations and prophylaxis received out of network. You have been asked to pay a 50% coinsurance for the oral evaluation (50% of $62 = $31) and prophylaxis (50% of $67 = $33.50). 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 the unspecified preventive procedure (D1999) or provide additional reimbursement for the comprehensive oral evaluation (D0150), and the prophylaxis (D1110) received December 10, 2020 from the out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services provided on March 27, 2020, to June 18, 2020 by an out of network (OON) provider.
You asked the Plan to pay for podiatry services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 podiatry services provided on March 27, 2020, to June 18, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prosthetic services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve prosthetic services. You say that you would like approval for these services. The Plan denied your request. The Plan says there are in-network providers available for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 prosthetic services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on December 3, 2020 by an out of network (OON) provider.
You asked the Plan to pay for outpatient hospital services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 outpatient hospital services provided on December 3, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a labial veneer (D2962) and the localized delivery of antimicrobial agents (D4381).
You asked the Plan to pre-approve the veneer and localized delivery of antimicrobial agents. You say that you are on a fixed income and cannot afford the treatment. You say that you paid $700 out of pocket with funds that you borrowed from family for the deep cleaning. You also say that you need to pay your family back. The Plan denied your request. The Plan says labial veneer is not listed as a covered service. The Plan says that localized delivery of antimicrobial agents is not listed as a covered service either.
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 labial veneer (D2962) and the localized delivery of antimicrobial agents (D4381).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care as of March 16, 2021.
You asked the Plan to pre-approve inpatient psychiatric care. You say that the enrollee is unable to maintain safety in the community at this time and needs 24-hour care. The Plan denied your request. The Plan says the denial of authorization for continued inpatient psychiatric care is correct, because the recommended level of care for the enrollee is outpatient.
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 inpatient psychiatric care. Our reviewer says that the enrollee does not meet the Medicare criteria for continued inpatient psychiatric level of care. Our physician reviewer found based upon the records provided, it is not expected that this enrollee would improve in a reasonable period of time beyond March 15, 2021 as he was not showing any dangerousness to self or others, auditory or visual hallucinations, or aggressive behaviors while not showing any acute threats of safety. The enrollee was cooperative with medication and did not attend therapy. He has shown minimal improvement. It does not appear medically reasonable and necessary to continue having psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond March 15, 2021. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care as of March 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 29, 2020 by an out of network (OON) provider.
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 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 laboratory services provided on November 29, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh (78815).
You asked the Plan to pre-approve this service. You say that a PET scan is medically necessary for the enrollee. The Plan denied your request. The Plan says a PET scan is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that subsequent PET scans are covered only when 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 this service. Our reviewer says that this service is not medically necessary.
Our physician reviewer found that the enrollee has a diagnosis of a malignant neoplasm of the upper lobe, unspecified bronchus or lung. The enrollee was diagnosed with a large cell poorly differentiated neuroendocrine carcinoma of the lung in 2012. The enrollee was treated with a lobectomy and chemotherapy. There has been no treatment since 2013. A PET scan on July 17, 2020 showed no evidence of recurrence or metastatic disease. Additionally, magnetic resonance imaging (MRI) of the chest on July 27, 2020 revealed no suspicious osseous lesions in the ribs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh (78815).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a urology office visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve office visit. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a urology office visit to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the myocardial perfusion imaging to be provided by an out-of-network provider.
You asked the Plan to pre-approve the myocardial perfusion imaging. You say that your weight loss journey has been smooth until you joined the Plan. You say that you need the stress test approved. The Plan denied your request. The Plan says in-network providers are available to perform the service.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 the myocardial perfusion imaging to be provided by an out-of-network provider.