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

We decided that the Plan does not have to pre-approve a repeat facet injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show an appropriate level of pain control from the previous diagnostic injection.
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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the request does not meet the criteria of the LCD. The first injection should be interpreted as a negative test, as it did not achieve 80% pain relief. 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a repeat facet injection for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device and surgery for the enrollee.
You asked the Plan to pre-approve the Vertiflex device. You say that this procedure is medically necessary. The Plan denied your request. The Plan says this device is not covered by Medicare.
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 Vertiflex device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex spacer device is experimental. More research is needed to show safety and efficacy. Medicare coverage criteria are 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 Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device and surgery for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTecentriq.You asked the Plan to pre-approveTecentriq. You say that the requested Tecentriqis medically necessary.The Plan denied your request. The Plan says the requested Tecentriq is not medically necessary.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-approveTecentriq. Our reviewer says that the requested Tecentriq is not medically necessary. Our physician reviewer found the enrollee is diagnosed with hepatocellular carcinoma. The requested use of Tecentriq is not FDA-approved for the enrollee's diagnosis. This enrollee has already progressed on a checkpoint inhibitor and the combination of Tecentriq with bevacizumab is for 1st line treatment and this enrollee has had several prior lines of therapy.We looked at this physician's review, the file, and Medicarerules. Based on this information, we decided that Medicare rules for coverage of Tecentriq have not been met.Therefore, we decided that the Plan does not have to pre-approveTecentriq.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on October 26, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you do not feel you should have to pay this copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 $120 copayment for emergency care. You have been asked to pay a $120 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The medical record shows you received services during your emergency room 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 visit provided on October 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pay fordental services (D3331) provided to the enrollee on August 27, 2020.You asked the Planto pay forthe services. You say that this should bepaid for.The Plandenied your request. The Plansaysthis is not listed as 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 Plandoes not haveto pay fordental services (D3331) provided to the enrollee on August 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora second cervical spine computed tomography provided.

You asked the Plan to pay fora second cervical spine computed tomography, professional component. You say that the Plan should pay this claim.The Plan denied your request. The Plan says this is a duplicate claim to the one paid on March 9, 2020.

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 a second cervical spine computed tomography,professional component is not supported in the medical record. Based on this information, we decided that Medicare rules for coverage of a second cervical spine computed tomography have not been met.Therefore, we decided that the Plan does not have to pay fora second cervical spine computed tomography provided.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.
You asked the Plan to pre-approve Retacrit. You say that the requested Retacrit is medically necessary. The Plan denied your request. The Plan says the requested Retacrit is not medically necessary.
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 Retacrit. Our reviewer says that the requested Retacrit is not medically necessary. Our physician reviewer found the enrollee's whose symptom complex presentation includes the diagnosis of Adenocarcinoma of Lymphoepithelioma-like variant of the stomach resection, status post partial gastrectomy with local recurrence, status post radiation therapy and now recurrence and bleeding, and is on supportive care. The requested use of Retacrit is not FDA-approved for the enrollee's diagnosis. The enrollee's current hemoglobin is greater than 11. Based on major drug compendia, a patient's hemoglobin should be under 11 for injection. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveperiodontal scaling and root planing (D4341).You asked the Planto pre-approvethe dental services. You say that you have too much bacteria andneed the deep cleaning.The Plandenied your request. The Plansaysthis 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 Plandoes not haveto pre-approveperiodontal scaling and root planing (D4341).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe minor surgery provided on September 17, 2020.You asked the Plan to waive the copayment forthe minor surgery. You say that you have received thissame service and have had to pay a different copayment amount. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.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 $200 copayment for each visit to an ambulatory surgical center. You have been asked to pay a $200 copayment for the minor surgery. The minor surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 forthe minor surgery provided on September 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted tothe current acute care hospital with altered mental status related to recent COVID-19 infection requiring CPAP at home. She was diagnosed with pneumonia, PE, and acute kidney injury and placed on BiPAP as well as antibiotics and Xarelto. Her decubitus ulcers were treated with daily basic wound care with special mattress.The enrollee is stable and improving according to the notes and only requires short term additional acute care services which can safely be administered at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. 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 forLTACH services will be considered not medically necessary at this time.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-approvelong term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe moderate sedation services provided from November 6, 2019, to November 7, 2019.You asked the Plan to pay forthe services provided. The Plan denied your request. The Plan says the billed service cannot be verified.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological statusWe find that CPT code 99152 is not supported in the medical record. Specifically, the records do not indicate the sedation services required the presence of an independent trained observer. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met.
Therefore, we decided that the Plan does not have to pay forthe moderate sedation services provided from November 6, 2019, to November 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe pneumatic compression device provided on September 9, 2020.You asked the Plan to pay forthe provided device. You say that complications and risk factors can be minimized with the use of this device.The Plan denied your request. The Plan says the device is not covered to prevent deep vein thrombosis during or following surgery.The Plan must follow Medicare rules. Medicare rules say that Items that are used for a preventative service or function are excluded from coverage under theMedicare DME benefit.We looked at thefile, and Medicare rules. A pneumatic compression devicethat provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service. Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pay forthe pneumatic compression device provided on September 9, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forfull mouth x-rays (D0210) provided September 3, 2020.You asked the Plan to pay forthe full mouth x-rays. You say that the services were medically necessary.The Plan denied your request. The Plan says only bite-wing x-rays are covered under your 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 forfull mouth x-rays (D0210) provided September 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the periapical x-ray (D0220) provided on October 9, 2020.
You asked the Plan to pay for the dental services. You say that you were advised that you are entitled to 2 oral exams per year and no time frame in between the 2. You also say that you had 2 follow ups for a bad tooth and got 2 denied claims. The Plan denied your request. The Plan says the provider in this case is not a participating provider. The Plan says that dental services that you receive from a non-participating provider are not 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, dental services that you receive from a non-participating provider are not among those covered under this benefit. The Evidence of Coverage clearly states that services are only covered when received by a participating provider. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the periapical x-ray (D0220) provided on October 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waivethe copayment for the lab services you received on August 21, 2020.You asked the Plan to waivethe copayment. You say that this was for your annual wellness visit.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 (such as copayments, deductibles and coinsurance). Your contract withthe Plan clearly says that you must pay a $10 copayment for Medicare-covered lab services. Review of the file shows that you were provided lab services on August 21, 2020. You have been asked to pay a $10 copayment for the services. The services fall within the outpatient diagnostic tests benefit category. Lab services are not included in the annual wellness visit benefit. 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 waivethe copayment for the lab services you received on August 21, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the co payment for the urgent care visit provided.

You asked the Plan to waive the co payment for the urgent care visit. You say that you should not be liable for the urgent care co payment because you were told that the Covid test was covered in full. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $60 co payment per visit for covered services to an in-network or out-of-network medical facility or urgent care center. 

You have been asked to pay a $60 co payment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" benefit category. The record shows a separate claim was filed for the Covid testing which was covered in full by the Plan.

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 co payment for the urgent care visit provided.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on December 10, 2019.
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on December 10, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on December 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forcytogenetics and molecular cytogenetics, interpretation and report (CPT Code 88291) provided to the enrollee on August 7, 2020.You asked the Plan to pay forthe laboratory services. You say that the claim should be paid.The Plan denied your request. The Plan says no medical records were provided to verify if the services were necessary and the Plan asked for the records numerous times.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. We cannot determine how the enrollee came to the servicing provider or whether the services are medically necessary. Non-contracted providers are required to furnish necessary information to the health plan when requested.Therefore, we decided that the Plan does not have to pay forcytogenetics and molecular cytogenetics, interpretation and report (CPT Code 88291) provided to the enrollee on August 7, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the Medicare Part B prescription drugs, physical therapy, outpatient surgery, and radiology services provided from May 2, 2020, to May 4, 2020.

You asked the Plan to waive the cost share for the Medicare Part B prescription drugs, physical therapy, outpatient surgery, and radiology services. You say that you feel it was an inpatient admission. The Plan denied your request. The Plan says you were charged the cost sharing 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 cost sharing for the outpatient services. 

You have been asked to pay coinsurance and copayments for the Medicare Part B prescription drugs, physical therapy, outpatient surgery, and radiology services. The Medicare Part B prescription drugs, physical therapy, outpatient surgery, and radiology services fall within the outpatient benefit categories. 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 cost share for the Medicare Part B prescription drugs, physical therapy, outpatient surgery, and radiology services provided from May 2, 2020, to May 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 20, 2020. You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 medical services provided to the enrollee by an out-of-network provider on October 20, 2020.