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

We decided that the Plan does not have to pay for the comprehensive gene panel provided on April 14, 2021.
You asked the Plan to pay for the testing services. You say that you have no knowledge of the enrollee's coverage prior to the specimen's arrival. The Plan denied your request. The Plan says the billed services cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary.
We looked at the file and the rules. We find that genetic testing is not supported in the medical record. Specifically, the records do not show that the results of the testing would be used in the management of the enrollee's specific medical problem. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive gene panel provided on April 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Monovisc.
You asked the Plan to pre-approve Monovisc. The Plan denied your request. The Plan says the step therapy criteria has not been met.
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 Monovisc. Our reviewer says that Monovisc is not medically reasonable and necessary in this case. Our physician reviewer found that The enrollee has not trialed one viscosupplemental treatment such as Durolane, Euflexxa, Supartz, or Gelsyn-3. Step therapy, as outlined by the plan, requires that one of these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Monovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Monovisc.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for core buildup provided on April 26, 2021.
You asked the Plan to pay for core buildup. You say that the code was submitted incorrectly and there is no code equivalent to a replacement crown. You say that the procedure was medically necessary service that should be reimbursed. The Plan denied your request. The Plan says the service is not a covered benefit and you will not receive additional reimbursement.
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. Please note, the Plan made partial payment for the crown based on your benefits. Therefore, we decided that the Plan does not have to pay for core buildup provided on April 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay the duplicate claim for the magnetic resonance imaging provided on August 8, 2020.
You asked the Plan to pay for Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material (72141). You say that the payment was retracted, so the Plan should pay the claim. The Plan denied your request. The Plan says the original claim was retracted for an incorrect payment amount.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The record shows the original claim was retracted on April 16, 2021 but the corrected amount had been paid on October 7, 2020. Based on this information, we decided that Medicare rules for coverage of Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material (72141) have not
been met. Therefore, we decided that the Plan does not have to pay a duplicate claim for the magnetic resonance imaging provided on August 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis provided on March 11, 2021.
You asked the Plan to pay for the prophylaxis. You say that there was no in-network dentist in your location and the Plan should approve the visit. The Plan denied your request. The Plan says there is no benefit for dental services performed by an out-of-network provider. The Plan also says that you were provided 3 in-network dentists prior to receiving the service.
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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the prophylaxis provided on March 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit you had with a gynecologist on March 22, 2021.
You asked the Plan to waive the copayment for the gynecology visit. You say that you are appealing this charge. The Plan denied your request. The Plan says you were charged this copayment 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 visits with a specialist. You have been asked to pay a $45 copayment for the gynecology visit. The gynecology visit falls within the visits with a specialist 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 visit you had with a gynecologist on March 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office provided on January 8, 2021 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 an office provided on January 8, 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 inpatient psychiatric care from August 25, 2021, forward.
You asked the Plan to pre-approve inpatient psychiatric care. You say that inpatient psychiatric care from August 25, 2021, forward, is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for inpatient psychiatric care, from August 25, 2021, forward. The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric care. Our reviewer says that it did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the date in question of August 25, 2021, forward. Our physician reviewer found the enrollee did not appear to require inpatient mental health treatment beyond August 25, 2021, forward, as she was not a danger to herself or others and did not have any auditory or visual hallucinations while being cooperative with treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis beyond the date in question. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from August 25, 2021, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray provided on April 1, 2021.
You asked the Plan to pay for the panoramic x-ray. You say that you had problems with two dental offices. You say that you found a private dentist and no longer need the Plan's services. The Plan denied your request. The Plan says the Plan already issued reimbursement for a full mouth series of x-rays.
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, you also have maximum benefit of one complete series x-ray or panoramic x-ray ever five years. The Plan paid for a complete series x-ray provided on February 12, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray provided on April 1, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for catheter placement (36215) and an angiogram (75710) provided on November 17, 2020.
You asked the Plan to pay for catheter placement and an angiogram. You say that these codes are documented. The Plan denied your request. The Plan says that these codes are not supported.
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 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 catheter placement and an angiogram. Our reviewers says that the billed codes are supported. Our physician reviewer found the documentation supports diagnostic testing above the fistula segment. When a catheter is maneuvered from a puncture of the dialysis graft/ fistula into the proximal inflow vessel for formal extremity diagnostic arteriography, code 36215 (first order cauterization) and code 75710 (unilateral extremity angiogram) are reported separately. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of catheter placement and an angiogram have been met. Therefore, we decided that the Plan has to pay for catheter placement (36215) and an angiogram (75710) provided on November 17, 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: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory testing provided on March 3, 2021.

You asked the Plan to pay for lab tests. You say that your primary care provider requested that you use this provider instead of the designated site. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because this testing was not performed at your primary care provider's designated site.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.

This testing was both ordered and performed by in-network providers. The file does not show that the Plan provided notice that lab tests would not be covered. Under Medicare rules, this means lab tests is considered approved by the Plan. Therefore, we decided that the Plan has to pay for laboratory testing provided on March 3, 2021.

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: Transportation
Decision: Favorable

We decided that the Plan has to pay for non-emergency ambulance transportation (A0428 x2), and ground
mileage (A0425) provided on September 16, 2020.
You asked the Plan to pay for non-emergency ambulance transportation, and ground mileage. You say that you
want the Plan to pay. The Plan denied your request. The Plan says that information provided at the time of the
appeal does not support ambulance transportation. A physician's office/clinic/outpatient clinic/outpatient
surgery center is not a covered destination.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.
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 non-emergency ambulance transportation,
and ground mileage. Our reviewer says that other means of transportation were contraindicated for this
enrollee. The enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a
fully equipped ambulance can provide for safe transportation. Documentation supports that the ambulance
transport was medically reasonable and necessary for the enrollee. Our physician reviewer found that based on
the medical records, it would be considered medically appropriate to transport this enrollee via ambulance
services. The enrollee was non-ambulatory and required assistance to be moved in and out of a stretcher.
Additionally, the records indicate that the enrollee could not protect their airway. Therefore, the enrollee's
vitals would need to be carefully monitored.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of non-emergency ambulance transport, and ground mileage have been met.
Specifically, the ambulance transport was medically reasonable and necessary. Additionally, per COVID
guidelines, ambulance to a physician's office can be covered when medically necessary. Therefore, we decided
that the Plan has to pay for non-emergency ambulance transportation (A0428 x2), and ground mileage (A0425)
provided on September 16, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a home health blood glucose monitor (BGM).

You asked the Plan to pre-approve a home health BGM. You say that the services are necessary.The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that specific criteria must be met for coverage of home blood glucose monitors and related accessories and supplies.

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 home health BGM. Our reviewer says that the item is medically necessary. Our physician reviewer found you monitor your blood glucose 4 times per day and take a metered dose inhaler with adjustments in doses according to the blood glucose level. You also have hypo unawareness so you are an ideal candidate for and meets criteria fora continuous glucose monitor -ideally with an alarm which would include dexcom g6 or the freestyle libre 2.

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 home health BGM have been met. Therefore, we decided that the Plan has to pre-approve a home health blood glucose monitor (BGM).

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for ambulance services you received on May 2, 2021.
You asked the Plan to waive the cost sharing for the ambulance services. You say that you were transported without your permission as you didn't want to go to the emergency room. You say that you shouldn't have to pay for these services. The Plan denied your request. The Plan says you had not met your deductible at the time of these services.
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 $300 in-network deductible for all in-network services and a $100 for each ambulance transport once the deductible is met.
Records show that at the time of the ambulance transport, you had $202.34 remaining on your deductible. That is why you were charged this amount in addition to the applicable $100 copayment for ambulance services. This cost sharing applies regardless of the reason for the ambulance transport. Your Evidence of Coverage clearly discloses that you have a $300 deductible and thereafter a $100 copayment for ambulance services. There is no provision in your contract for a waiver of this amount for any reason. Therefore, we decided that the Plan does not have to waive the cost sharing for ambulance services you received on May 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device provided to the enrollee on November 16, 2020.
You asked the Plan to pay for this claim. You say that this equipment was ordered for the enrollee for use before and after surgery. The Plan denied your request. The Plan says Medicare billing criteria are not met.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This equipment was used during and after a surgical procedure by the facility.
Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility or hospital. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device provided to the enrollee on November 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve battery replacement for a spinal cord stimulator for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no clinical documentation showing good pain control with the current device.
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 services. 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 that the working stimulator is effective in reducing the enrollee's pain. The criteria for battery replacement is not met.
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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve battery replacement for a spinal cord stimulator for the enrollee.
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 admission to an IRF is medically necessary. The Plan denied your request. The Plan says the request does not meet criteria for medical necessity.

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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on January 10, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that this copayment is excessive and you are on a fixed income. The Plan denied your request. The Plan says you were charged this copayment 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 $90 copayment for visits to the emergency room. You have been asked to pay a $90 copayment for the ER visit. 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 emergency room (ER) visit you had on January 10, 2021.