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

We decided that the Plan does not have to pay for the medical services provided by an out-of-network provider on June 4, 2019.You asked the Plan to pay for theservices. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not authorized.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 services 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 forthe medical services provided by an out-of-network provider on June 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 18, 2019 by out of network provider.You asked the Plan to pay foroutpatient lab work. You say that this was an extension of an office visit.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also an out-of-network provider.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 forthe medical services provided on July 18, 2019 by out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cyclobenzaprine tablets.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says self-administered drugs are not covered.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approvecyclobenzaprine tablets.Benefits for these servicesmay be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the guided tissue regeneration, two surgical placements of implant bodies: endosteal implants, first 15 minutes of deep sedation/general anesthesia, each subsequent 15 minute increment of deep sedation/general anesthesia, and drugs or medicaments dispensed in the office for home use provided on September 4, 2019.
You asked the Plan to pay for the guided tissue regeneration, endosteal implants, deep sedation/general anesthesia services, and drugs or medicaments. You say that these services were necessary in order to receive the positive outcome of having teeth in your mouth. The Plan denied your request. The Plan says these services are not covered benefits under your plan.
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 guided tissue regeneration, two surgical placements of implant bodies: endosteal implants, first 15 minutes of deep sedation/general anesthesia, each subsequent 15 minute increment of deep sedation/general anesthesia, and drugs or medicaments dispensed in the office for home use provided on September 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the OncotypeDx Prostate Cancer Assay rendered to the enrollee on April 15, 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 the services were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that the OncotypeDx Prostate Cancer Assay 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 had a diagnosis of malignant neoplasm of the prostate. The pathology report dated April 15, 2019 documents prostatic adenocarcinoma with a Gleason score of 7 (3+4)/Grade group 2. The urologist documents that the enrollee may require active treatment. He did not have very low risk disease. He did not meet the criteria for coverage of the OncotypeDx testing. The testing was 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 OncotypeDx Prostate Cancer Assay rendered to the enrollee on April 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on May 6, 2019.You asked the Plan to pay forthe lab service. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the lab service have not been met.Therefore, we decided that the Plan does not have to pay forthe lab services provided on May 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse the full amount for the periodic oral evaluation (D0120 x 2), and the prophylaxis (D1110 x 2) provided from February 7, 2019 to August 15, 2019.
You asked the Plan to reimburse the full amount for the dental services. You say that you should be reimbursed an additional $174. You say that you have paid a total of $194 and were only reimbursed $160. The Plan denied your request. The Plan says the services were processed correctly. The Plan says the services were paid at the allowed amount. The Plan also says that since the services were received out of network, the provider can charge more than the allowed amount.
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 the Medicare allowed amount. Since you received the services out of network, the provider can charge more than the allowed amount however, the Plan is not responsible for anything over the allowed amount. Therefore, we decided that the Plan does not have to reimburse the full amount for the periodic oral evaluation (D0120 x 2), and the prophylaxis (D1110 x 2) provided from February 7, 2019 to August 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for urgent care services provided on June 7, 2019 through June 25, 2019.You asked the Plan to pay for the urgent care services. You say that your arm was bleeding and the nearest network facility was an hour away. The Plan denied your request. The Plan says the services provided were not authorized and are not payable.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 care that cannot be provided by network providers.The "urgent care clinic" is not a network provider with the Plan. 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 urgent care services. Our reviewer says that it would have been reasonable,given the circumstances, to obtain the services through the Health Plan. Our physician reviewer found that according to the appeal, in network service was available within an hour's time of your location. The wound was acute but there was no significant blood loss and it would have been medically reasonable to obtain care at an in network facility. The services were medically necessary but not immediately required.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 urgent care services have not been met. 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 pay for the urgent care services. Therefore, we decided that the Plan does not have to pay for urgent care services provided on June 7, 2019 through June 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit and related medical services provided on May 30, 2019 by out of network provider, "the doctor". You asked the Plan to pay forthe office visit and related medical services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.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 doesnot have to pay forthe office visit and related medical services provided on May 30, 2019 by out of network provider,"the doctor".
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveendodontic therapy (code D3330) and core buildup, including any pins when required (code D2950).You asked the Plan to pre-approvethe endodontic therapy and core buildup. The Plan denied your request. The Plan says Medicare doesnot cover these services and therefore these services are not covered by your plan.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-approveendodontic therapy (code D3330) and core buildup, including any pins when required (code D2950).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ofev capsules You asked the Plan to pre-approveself-administered drugs. You say that you are appealing with records.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are notamong the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve Ofev capsulesBenefits for self-administered drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by out of network provider, "the doctor". You asked the Plan to pre-approvephysician services. You say that you would like a referral for a follow-up visit.The Plan denied your request. The Plan says there are in-network providers available for these services. The Plan says that you can safely transition to an in-network provider as no pending testing and condition addressed an ongoing treatment plan established.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 pre-approved care.The requested provider in this case is not a networkprovider 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-approvethe medical services to be provided by out of network provider, "the doctor".
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound providedon August 16, 2019.You asked the Plan to pay for the ultrasound. The Plan denied your request. The Plan saysthatthe Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 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 thePlan. 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 thePlan does not have to pay for an ultrasound providedon August 16, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a porcelain or ceramic crown (code D2740) and core buildup (code D2950).You asked the Plan to pre-approve porcelain or ceramic crown and core buildup. The Plan denied your request. The Plan says that the services are not medically necessary due to the lack of information presented.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. The Plan covers porcelain or ceramic crown and core buildup when the services are medically necessary and reasonable.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 porcelain or ceramic crown and core buildup. Our reviewer says that these services are medically necessary. Our physician reviewer found the documentation provided meets the criteria for a core buildup (D2950) and crown (D2740) for tooth #13.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of porcelain or ceramic crown and core buildup have been met.Therefore, we decided that the Plan has to pre-approvea porcelain or ceramic crown (code D2740) and core buildup (code D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a blood glucose test (82947) provided on May 22, 2019.You asked the Plan to pay for the blood glucose test. You say that you would like reconsideration based on the records submitted. The Plan denied yourrequest. The Plan says documentation submitted did not include lab results of Glucose; quantitative, blood (except reagent strip)The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must reportservices with the appropriate CPT code.In this case, the CPT Code Manual definition of code 82947 is glucose; quantitative, blood (except reagent strip).We asked our coder 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 blood glucose test. Our reviewer says that CPT code 82947 is not supported. Our reviewer found the record does not contain evidence that a blood glucose test was performed during this episode of care.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 blood glucose test have not been met. Therefore, we decided that the Plan does not have to pay for ablood glucose test (82947) provided on May 22, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve Vascepa 0.5mg capsule for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee has a medical only policy with the plan.The Plan must follow Medicare rules. The rules say that Medicare PartB generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plandoes not haveto pre-approveVascepa 0.5mg capsule for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee. You asked the Plan to pre-approveIRF care. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are 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 services are not medically necessary. Our physician reviewer found the enrollee is currently at home under the care of home health care. He was hospitalized from January 3, 2020 to January 16, 2020 with epigastric tenderness, vomiting, and was obtunded on admission. He is now walking 250feet with contact guard assist and needs minimal assist with transfers. He needs maximal assist with bed mobility and bowel and bladder management. He is medically stable with no evidence of a need for an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. He may benefit from further therapy but does not require an intensive therapy program in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicarerules 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 for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay fora domiciliary or rest home visit (99336), and the destruction of skin growth (17000) provided on July 18, 2019 to August 5, 2019 by out of network provider.You asked the Plan to pay fora domiciliary or rest home visit, and the destruction of skin growth. You say that along with your appeal you sentinmedical records. You say that your records show that the claim denied for therequest of medical or no authorization. You further say that you are requesting a review of all information and to process the claim for available benefits.The Plan denied your request. The Plan says the services were not authorized because the provider is a non-network provider who does not work with the plan, and the provider is the referring provider who is not in-network. The member's primary care physician (PCP) did not refer for services. The health plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent oremergency situation, has been documented.Medicare rules say that plans canrequire 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 fora domiciliary or rest home visit (99336), and the destruction of skin growth (17000) provided on July 18, 2019 to August 5, 2019 by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.You asked the Plan to pre-approve incontinence supplies. You say that this is a quality of life issue.The Plan denied your request. The Plan says that this is not covered.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pre-approve incontinence supplies