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

We decided that the Plan does not have to pay for the physician's office surgery services coded as 20610, J7321 and G8427 provided on February 5, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the physician services. You say that according to the medical records, this treatment meets the medically necessary criteria. Therefore, you request immediate payment of the claim. The Plan denied your request. The Plan says non-emergent services with non-contracted providers require prior authorization before services being rendered.

Medicare rules that this PPO plan will generally cover your medical care as long as the care you receive is considered medically necessary and you receive your care from a provider who is eligible to provide services under Original Medicare. As a member of the PPO plan you can receive your care from either a network provider or an out-of-network provider.

The health plan rules apply in this case. The health plan contract on pages 83-84 specifically says prior authorization rules may apply for provider and professional services. 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 physician's office surgery services coded as 20610, J7321 and G8427 provided on February 5, 2021 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One for the enrollee.

You asked the Plan to pre-approve Synvisc-One. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that there is no indication their preferred agents would likely be less effective, and/or cause adverse effects for the member.

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 Synvisc-One. Our reviewer says that Synvisc-One is not medically reasonable and necessary for the enrollee. The patient has not tried and failed Monovisc and Orthovisc. The documentation does not support that Monovisc and Orthovisc would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Synvisc-One. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says care can be safely received in another setting.

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 the records show that that the enrollee is improving and stable but may still require additional short-term acute care services which can be safely administered at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility or a lower level of care. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care may be considered when treatment has completed.

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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a 2D oral/facial photographic image (D0350) provided on April 1, 2021.

You asked the Plan to pay for a 2D oral/facial photographic image. You say that you were not aware that the service would not be covered. The Plan denied your request. The Plan says the service at issue is not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 2D oral/facial photographic image (D0350) provided on April 1, 2021.
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 the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary or reasonable.
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 the enrollee does not require services that they are not currently receiving at an acute care hospital, but that would be available at the LTACH 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 LTACH services have not been met. Specifically, the LTACH does not offer any medically necessary services for this enrollee that they are not already receiving at their current level of care. This means admission into a LTACH is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided by a
participating provider on February 15, 2021.

You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you had a colonoscopy.
You say that you did not have an outpatient surgery. 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 $225
copayment for outpatient surgery/in-network.

You have been asked to pay a $225 copayment for a diagnostic colonoscopy. Evidence was provided to show
that a polyp was found and removed. The rules say that, if during the course of the screening colonoscopy, a
lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic
procedure classified as a colonoscopy with biopsy or removal should be billed. A diagnostic colonoscopy falls
within the outpatient surgery/in-network 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 a diagnostic colonoscopy provided by a participating provider on February 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the evaluation, deep cleaning and extraction of a tooth with a periodontist.

You asked the Plan to pre-approve the dental services. You say that you would like reconsideration because the services of a periodontist are necessary due to your heart condition. The Plan denied your request. The Plan says the requested service is not included in the contract 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. Specifically, you are requesting that a periodontist render the requested services. Periodontists are not general dentists. Therefore, we decided that the Plan does not have to pre-approve the evaluation, deep cleaning and extraction of a tooth with a periodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), an intraoral periapical radiographic image (D0220), and drugs or medicaments dispensed in the office for home use (D9630) provided on February 26, 2021.
You asked the Plan to pay for a limited oral evaluation, an intraoral periapical radiographic image, and drugs or medicaments dispensed in the office for home use. You say that the services at issue were medically necessary. The Plan denied your request. The Plan says you are not covered for this service when seen by an out-of-network provider.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of a limited oral evaluation, an intraoral periapical radiographic image, and drugs or medicaments dispensed in the office for home use have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), an intraoral periapical radiographic image (D0220), and drugs or medicaments dispensed in the office for home use (D9630) provided on February 26, 2021.
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 services can be provided at a lower level of care.

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 the enrollee was admitted to the acute care hospital for back pain and compression fracture. Her medical conditions are stable. There are no complex nursing needs. She does not require treatment by multiple therapies in an intensive rehabilitation therapy program. She does require physical and occupational therapy but there is no documented need for an intensive rehabilitation 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on March 3, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
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 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 for the services provided by an out-of-network provider on March 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), a teeth cleaning (D1110), and an intraoral complete series of radiographic images (D0210) provided on February 24, 2021.

You asked the Plan to pay for a periodic oral evaluation, a teeth cleaning, and an intraoral complete series of radiographic images. You say that you were told that the services at issue would be covered. The Plan denied your request. The Plan says you are responsible for services provided by privately contracted providers.

The Plan will not reimburse for charges incurred by Medicare Opt Out providers.

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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation, a teeth cleaning, and an intraoral complete series of radiographic images have not been met. Specifically, services were provided by an Opt Out provider. The Plan does not cover dental services when provided by an Opt Out provider. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), a teeth cleaning (D1110), and an intraoral complete series of radiographic images (D0210) provided on February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar medial branch blocks.

You asked the Plan to pre-approve Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (64493) and Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure) (64494). You say that the enrollee has severe pain and has a hard time doing regular activities. The Plan denied your request. The Plan says the notes do not show how severe the enrollee's back pain is.

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 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (64493) and Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure) (64494). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating that the facet joint is the origin of the enrollee's pain. The review has determined that the injections are not medically reasonable or necessary. The provided documentation does not indicate that the enrollee meets criteria for the injections.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (64493) and Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure) (64494) have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar medial branch blocks.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on February 12, 2021, by an out of network (OON) provider.

You asked the Plan to pay for an office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says services were provided by an out-of-network provider without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 an office visit (99214) provided on February 12, 2021, by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need 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. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to be able to perform fifteen hours per week of rehabilitative services with regular physician evaluation. Your care needs can be met at a lower level of care. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. 

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on December 22, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 office visit provided on December 22, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Guardant360 Liquid Biopsy (CPT code 81455), 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 the enrollee has parotid gland (glands that sit just in front of the ears on each side of the face that produce saliva to aid in chewing and digesting food) cancer. The Plan states the enrollee had a Computed Tomography (an imaging study using X-rays) of the brain on May 13, 2021, and it showed that the enrollee has cancer that involved the left side of the brain. The Plan states the notes do not show the enrollee has cancer that did not originate from the central nervous system such as mentioned 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 the service. Our physician reviewer found the record indicates that the enrollee has biopsy proven acinic cell cancer of the parotid gland that is metastatic to bone. The records indicate that the enrollee also has a lesion that is destructive to the skull and involves the brain. The provided records indicate that the prescriber believes this to be of parotid origin. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 

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 Guardant360 Liquid Biopsy (CPT code 81455), for the enrollee.