Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the critical care services (99291) provided on May 5, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the services are not payable as state regulated payment limitations apply.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan did not provide evidence to support their rationale to deny payment for this service. Therefore, we decided that the Plan has to pay for the critical care services (99291) provided on May 5, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the comprehensive oral evaluation (D0150), the complete series x-ray (D0210), and the unspecified preventive service (D1999) provided on December 23, 2020.
You asked the Plan to pay the in network rate for the dental services. You say that you were experiencing excruciating tooth pain. You say that you needed a tooth extracted. You say that a plan representative helped you find this provider. You say that you were advised the extraction would be covered. You say that you had an oral evaluation. You say that you are being charged $187. You also say that you need help paying for this. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered once every 3 calendar years. The Plan says that 1 complete series x-ray or panoramic x-ray is covered every 5 calendar years. The Plan also says that the frequency limits have been exceeded.
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 and comprehensive oral evaluation and complete series x-ray are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation and a panoramic x-ray that you received on October 8, 2019. Additionally, unspecified preventive service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay the in network rate for the comprehensive oral evaluation (D0150), the complete series x-ray (D0210), and the unspecified preventive service (D1999) provided on December 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve liver and spleen imaging; static only (CPT code 78215),
for the enrollee.

You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your
request. The Plan says they did not receive results of an ultrasound (picture study using sound waves) that were
limited or failed to diagnose (find the source of) the enrollee's problem. The Plan states they did not receive
physical exam results that show a reason this study is needed. The Plan states the enrollee's records did not
include a detailed history that shows this study is needed.

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 service. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found there is no specific clinical rationale for the requested study. There are no physical exam
abnormalities noted and the liver function is normal. There was no abdominal ultrasound obtained. The review
has determined that the items/services at issue in this case are 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 the service have not been met. Therefore, we decided that the Plan does not
have to pre-approve liver and spleen imaging; static only (CPT code 78215), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two core buildups, including any pins when required and preventive procedure provided on August 10, 2020.

You asked the Plan to pay for the core buildups and preventive procedure. You say that you believe the enrollee should not be held responsible for these charges. The Plan denied your request. The Plan says these services are not covered. The Plan also says that no contacts were made to the Plan prior to the date of service to verify benefits and provider eligibility.

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 two core buildups, including any pins when required and preventive procedure provided on August 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the root surgery for a premolar tooth (D3421), the root surgery for a molar (D3425), and the retrograde filling (D3430 x 2) provided on December 21, 2020.
You asked the Plan to pay for the dental services. You say that you are being charged $889. You say that you already paid $1,009. You also say that you bought the dental rider which was effective December 1, 2020. The Plan denied your request. The Plan says the services you received are not listed as 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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the root surgery for a premolar tooth (D3421), the root surgery for a molar (D3425), and the retrograde filling (D3430 x 2) provided on December 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on October 1, 2020.
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing was not authorized and the enrollee is not a patient of the ordering provider's office.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab services billed on this claim. The lab requisition submitted indicates a request for a Wellness Panel, and while the form indicates that a definition of this panel is attached, no definition was provided to show that this panel constitutes the specific lab codes billed on the claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on October 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consult with an out of network proton therapy provider.

You asked the Plan to pre-approve a consult with an out of network proton therapy provider. You say that the enrollee wants to try proton therapy for treatment. The Plan denied your request. The Plan says the National Comprehensive Cancer Network guidelines do not prefer proton therapy as the radiation therapy choice.

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 a consult with an out of network proton therapy provider. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found per National Comprehensive Cancer Network (NCCN) radiation compendia, definitive radiation options are external beam and brachytherapy. Proton beam is not a listed option.

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 consult with an out of network proton therapy provider have not been met. Therefore, we decided that the Plan does not have to pre-approve a consult with an out of network proton therapy provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating provider on January 4, 2021.
You asked the Plan to waive the copayment for lab work. You say that you would like this paid. You say that this was lab work that was done with your annual wellness exam. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $10 copayment for outpatient diagnostic tests/lab test. You have been asked to pay a $10 copayment for lab work. When additional services are provided during an annual wellness exam, additional copayments are applied; therefore, the correct copayment has been applied. Lab work falls within the outpatient diagnostic tests/lab test 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 lab work provided by a participating provider on January 4, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve use of Keytruda.
You asked the Plan to pre-approve Keytruda. You say that the enrollee does not have any good alternative treatment options if/when his disease relapses after stopping Keytruda. The Plan denied your request. The Plan says that the denial of authorization for this drug is correct, because studies have not proven that continued treatment with Keytruda for more than 24 months is safe and helpful.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Keytruda. Our reviewer says that the enrollee meets the Medicare criteria for the requested use of Keytruda. Our physician reviewer found the requested use of Keytruda is Food & Drug Administration (FDA) approved for the enrollee's diagnosis. National Comprehensive Cancer Network (NCCN) guidelines state that Keytruda can be used until toxicity or progression or 24 months. Mayne experts will continue until toxicity or progression given the high risk of recurrence. The documentation supports that the requested use of Keytruda is safe and effective and otherwise reasonable and necessary for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have been met. Therefore, we decided that the Plan has to pre-approve use of Keytruda.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not need an intensive therapy program with multiple visits from a rehab doctor.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that you were admitted to the acute hospital for Covid-19. Your medical problems are stable. There are no complex nursing needs. You do not require treatment by multiple therapies, including either physical or occupational therapy, in 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you need IRF services because of injuries. The Plan denied your request. The Plan says you can safely receive needed services in other settings.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible charge for the services you received on January 5, 2021.
You asked the Plan to waive the deductible. The Plan denied your request. The Plan says you are responsible for the cost share.
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 $750 deductible you have to pay out-of-pocket before the Plan will pay its share for your covered medical services. The service you asked the Plan to waive falls within the surgery services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible you have to pay out-of-pocket before the Plan will pay its share for your covered medical services. This cost sharing is a contractual obligation that had not been met at the time the deductible was received on January 5, 2021. Therefore, we decided that the Plan does not have to waive the deductible charge for the services you received on January 5, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services billed for date of service April 2, 2020.
You asked the Plan to pay for the home health services. You say that this should be processed as in-network. The Plan denied your request. The Plan says this was not filed on a valid type of bill.
The Plan must follow Medicare rules. Medicare rules say that the home health PPS recognizes only certain TOBs. This claim was filed on TOB 0323. This is not a valid TOB for a Medicare home health claim. Therefore, we decided that the Plan does not have to pay for the home health services billed for date of service April 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the pelvis, without contrast material (72192) provided on December 18, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 $275 copayment for CT scans performed by an in-network provider other than your primary care physician. You have been asked to pay $113.78 for the CT scan provided. This is the Plan allowed amount which is less than the applicable copayment for this service. 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 computed tomography (CT) scan of the pelvis, without contrast material (72192) provided on December 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromuscular junction testing provided on May 17, 2019.
You asked the Plan to pay for neuromuscular junction testing. You say that you are requesting that the Plan waive the timely filing requirements and cover this claim. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the enrollee did not have a necessary medical condition for this testing.
The Plan must follow Medicare rules. Medicare rules say that neuromuscular junction testing code 95937 is only covered for certain specific diagnoses. We looked at the file and Medicare rules. This service was not billed with a covered diagnosis code. Based on this information, we decided that Medicare rules for coverage of neuromuscular junction testing have not been met. Therefore, we decided that the Plan does not have to pay for neuromuscular junction testing provided on May 17, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a mastectomy (19304, 19350) for gender affirmation.
You asked the Plan to pre-approve a mastectomy. You say that this is medically necessary. The Plan denied your request. The Plan says that this is cosmetic.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 a mastectomy. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is female to male transgender and has gender dysphoria. The medical record indicates the enrollee has been receiving testosterone and is living as a male. The World Professional Association for Transgender Health guidelines indicate that mastectomy and creation of a male chest are indicated procedures for female to male patients with gender dysphoria. The requested procedure is medically reasonable and necessary as defined by Medicare rules. 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 mastectomy have been met. Therefore, we decided that the Plan has to pre-approve a mastectomy (19304, 19350) for gender affirmation.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.