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

We decided that the Plan does not have to pay for targeted genomic sequence analysis panel testing (code 81455) provided on February 11, 2021.
You asked the Plan to pay for genetic testing. You say that this testing was ordered to help determine the course of treatment for the enrollee. The Plan denied your request. The Plan says this test is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that targeted genomic sequence analysis panel code 81455 will be automatically denied as not medically necessary. We looked at the file and Medicare rules. This test is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for targeted genomic sequence analysis panel testing (code 81455) provided on February 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on October 2, 2020, to October 5, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for psychotherapy services. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that there are in-network physicians available to provide 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 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 psychotherapy services provided on October 2, 2020, to October 5, 2020 by an out-of-network (OON) provider.
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), a panoramic radiographic image (D0330), retainer crowns (D6750 x2), core
buildups (D2950 x2), and pontic (D6240) provided from April 15, 2020, through April 16, 2020.
You asked the Plan to pay for a limited oral evaluation, an intraoral periapical radiographic image, a panoramic
radiographic image, retainer crowns, core buildups, and pontic. You say that the services were medically
necessary. The Plan denied your request. The Plan says the services at issue are not covered benefits.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation
(D0140), an intraoral periapical radiographic image (D0220), a panoramic radiographic image (D0330),
retainer crowns (D6750 x2), core buildups (D2950 x2), and pontic (D6240) provided from April 15, 2020,
through April 16, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services that you provided on January 7, 2021.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for physician's services that you provided on January 7, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 28, 2020.
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 are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service
(POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on December 28, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on March 18, 2021.
You asked the Plan to pay for the hearing aids. You say that per your insurance, the Plan is supposed to cover
at least $350 per each hearing aid. The Plan denied your request. The Plan says the health Plan requires that the
hearing aid be prescribed by a network clinical audiologist. The Plan selects the provider or vendor that will
furnish the covered hearing aid.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only when prescribed by a network clinical audiologist and when the Plan selects the provider or
vendor that will furnish the covered hearing aid.
We looked at the file and the Plan's rules. The file shows that the hearing aids were not prescribed by a network
clinical audiologist and the Plan did not select the provider or vendor that furnished the hearing aids. Based on
this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore,
we decided that the Plan does not have to pay for hearing aids provided on March 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the group 3 power wheelchair with accessories (CPT
code(s): E1028, K0108 and K0849).
You asked the Plan to pre-approve the DME. You say that you currently have a group 2 powered wheelchair
and you need the group 3 power wheelchair. You state the group 3 wheelchair is small and less wide which
would be more maneuverable for you inside your home especially in the bathroom. The Plan denied your
request. The Plan says the group 3 powered wheelchair is not necessary. The Plan states they already approved
a group 2 powered wheelchair for you. The Plan must follow Medicare rules. The physiatry evaluation on May
28, 2021, recommended Group 2 power wheelchair. There is no mention of difficulty passing through
doorways of your home with the previous wheelchair. The evaluation states the original power wheelchair was
able to fit in all areas of the home without hazards. Therefore, the group 3 wheelchair is not medically
necessary based on recommendation from a licensed/certified physical therapist (PT). Therefore, we decided
that the Plan does not have to pre-approve the group 3 power wheelchair with accessories (CPT code(s):
E1028, K0108 and K0849).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low-dose computed tomography (LDCT) scan.
You asked the Plan to pre-approve a LDCT scan. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that for purposes of Medicare coverage of lung cancer screening with LDCT, beneficiaries must meet specific criteria. 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 LDCT scan. Our reviewer says that the services are not medically necessary. Our physician reviewer found CMS criteria for LDCT for lung cancer screening specify the enrollee must have at least 30 pack years of smoking and still smoking or having quit within the past 15 years. According to the provided history this enrollee does not qualify for LDCT due to quantification and duration of smoking history per CMS guidelines. 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 LDCT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a low-dose computed tomography (LDCT) scan.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the direct skilled nursing services of a registered nurse (G0299) provided on September 2, 2020.
You asked the Plan to pay for the direct skilled nursing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service has not been reported correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code G0299 is not supported in the record. Specifically, this claim has not been reported correctly. The service has not been submitted on an appropriate claim form and the claim does not include the required Q code for home health services. Based on this information, we decided that Medicare rules for coverage of the direct skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the direct skilled nursing services of a registered nurse (G0299) provided on September 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy services (52310) provided
February 11, 2021.
You asked the Plan to waive the copayment for the endoscopy services. You say that you believe this service
should not have a separate copayment. The Plan denied your request. The Plan says the copayment has
processed correctly in this case.
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 outpatient surgery services.
You have been asked to pay a $275 copayment for the endoscopy services. This service falls within the
outpatient surgery services benefit category. This means that you have been asked to pay the correct amount
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the
endoscopy services (52310) provided February 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Positron emission tomography (PET) services provided
on January 14, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the PET services provided by an OON provider. 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 Positron emission tomography (PET) services provided on January 14, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a filling (D2392) provided on April 21, 2021.
You asked the Plan to pay for a filling. You say that you want the Plan to pay for the service. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of 2 per calendar year.
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 filling have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service. Therefore, we decided that the Plan does not have to pay for a filling (D2392) provided on April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection.
You asked the Plan to pre-approve lumbar epidural. You say that this is needed for the enrollee to obtain maximum function, reduced pain, and a better quality of life. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is no documentation to support an injection to a second level or segment of the lumbar spine.
The Plan follows Medicare rules. Medicare rules state that lumbar epidural steroid injections may be covered under certain clinical indications. 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 lumbar epidural. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested lumbar epidural. Our physician reviewer found there is no documentation of the degree of clinical response to previous injection therapy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar epidural have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar epidural steroid injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a medical eye examination and evaluation
(92014 x2) provided from March 15, 2021, through May 10, 2021.
You asked the Plan to waive the copayment for a medical eye examination and evaluation. You say that the
services should be covered. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45
copayment for vision care. You have been asked to pay a $90 ($45 x2) copayment for a medical eye examination and evaluation. The services at issue fall within the vision care benefit category. This means that you have been asked to pay the
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment
for a medical eye examination and evaluation (92014 x2) provided from March 15, 2021, through May 10,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the standard wheelchair and seat lift mechanism placed over or on top of toilet provided from non-certified Medicare providers from November 1, 2020 to November 2, 2020.
You asked the Plan to pay for the standard wheelchair and seat lift mechanism. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the standard wheelchair and seat lift mechanism placed over or on top of toilet provided from non-certified Medicare providers from November 1, 2020 to November 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency ambulance transportation
(A0429, A0425) provided on March 17, 2021.
You asked the Plan to waive the copayment for emergency ambulance transportation. You say that it was not
an emergency. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $240
copayment for ambulance services. You have been asked to pay a $240 copayment for emergency ambulance transportation. The service at issue
falls within the ambulance services 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
emergency ambulance transportation (A0429, A0425) provided on March 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for prostatic arterial embolization provided on October 30, 2020.
You asked the Plan to pay for vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction (37243), injection, anesthetic agent; superior hypogastric plexus (64517), angiography, pelvic, selective or supraselective, radiological supervision and interpretation (75736), and computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with
contrast material, including 3D image postprocessing (including evaluation of cardiac structure and
morphology, assessment of cardiac function, and evaluation of venous structures, if performed) (75574). You
say that the diagnosis is covered, and treatment decisions were made by an attending physician personally
familiar with the enrollee. The Plan denied your request. The Plan says there is no documentation that the
enrollee is participating or enrolled in a clinical trial and clinical value and effectiveness have not been
demonstrated in the peer-reviewed literature.
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 prostatic arterial embolization. Our reviewer
says that the services were not considered medically reasonable and necessary in this case. Our physician
reviewer found prostatic arterial embolization (PAE) is considered an experimental technique to treat
symptomatic benign prostatic hyperplasia. Very limited studies have demonstrated possible short-term safety
and efficacy. The most recent American Urological Association (AUA) guidelines do not recommend this
procedure outside of a clinical trial setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of prostatic arterial embolization, (37243, 64517, 75736, 75574) have not been
met. Therefore, we decided that the Plan does not have to pay for prostatic arterial embolization provided on
October 30, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care after September 5, 2021.
You asked the Plan to pre-approve the continuation of SNF care. You say that this request is medically necessary. The Plan denied your request. The Plan says SNF care is no longer medically necessary and reasonable for your condition.
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 continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you are a 54-year-old female with Coronavirus. In this case, there are no identifiable skilled nursing service needs and no identifiable skilled therapy service needs. In addition, you do not require skilled nursing or therapy services on a daily basis. Finally, you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care after September 5, 2021.