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

We decided that the Plan does not have to pay for chiropractic office visits (99203, 99212), electrical
stimulation (G0283), hot or cold pack therapy (97010), mechanical traction therapy (97012), and therapeutic
exercises (97110) provided from February 9, 2021, to March 1, 2021.
You asked the Plan to pay for chiropractic office visits, electrical stimulation, hot or cold pack therapy,
mechanical traction therapy, and therapeutic exercises. You say that the combination of therapies that you
received was medically necessary and allowed you to recover faster. The Plan denied your request. The Plan
says these services are not covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for chiropractic office visits (99203, 99212), electrical stimulation (G0283), hot
or cold pack therapy (97010), mechanical traction therapy (97012), and therapeutic exercises (97110) provided
from February 9, 2021, to March 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 20, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a
physician who has furnished a consultation or treats an enrollee for a specific medical problem.
The file does not contain documentation of an established relationship between the enrollee and the ordering
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this
testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services
rendered on January 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Polysomnography (95811).
You asked the Plan to pre-approve a Polysomnography. You say that a splint night Polysomnography will define dysomnia and allow for a more precise diagnosis of pap. The Plan denied your request. The Plan says the criteria for a repeat sleep study was not met, but the criteria for a PAP titration was met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Polysomnography. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found a new diagnostic polysomnography is considered not medically necessary for this patient. This enrollee has obstructive sleep apnea, diagnosed on two separate polysomnography's, in 2009 and 2016. The enrollee now has recurrent symptoms despite automatic positive airway pressure (APAP) use. The diagnosis appears not to be in question, so the diagnostic portion of 95811 is not necessary. The enrollee would benefit from a full night PAP titration PSG, which has been approved. 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 Polysomnography have not been met. Therefore, we decided that the Plan does not have to pre-approve a Polysomnography (95811).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for infusion services and supplies (A4221, J1559, K0552) provided on December 8, 2020.
You asked the Plan to pay for infusion services and supplies. You say that the requested services and supplies are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for durable medical equipment have not been met.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the document provided as proof of delivery does not itemize the items delivered and therefore does not corroborate delivery of the items at issue in this case. The record does not contain a corresponding itemized invoice or packing slip. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for infusion services and supplies (A4221, J1559, K0552) provided on December 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the physical therapy services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the physical therapy services. You say that the patient does not feel comfortable with an in-network provider. The Plan denied your request. The Plan says they have a variety of in-network providers available to provide for the enrollee's medical needs.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the physical therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on September 1, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for genetic testing. You say that you would like this claim reprocessed and paid due to medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 genetic testing provided on September 1, 2020 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided by an out-of-network provider on February 26, 2021, March 1, 2021, March 5, 2021 and March 15, 2021.
You asked the Plan to pay for physical therapy. You say that the office, individual provider and referring provider are all participating providers with Medicare. You say that the denial should be reconsidered since the patient's health plan is a dual Medicare plan and the services should be processed for payment. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and 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 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 physical therapy provided by an out-of-network provider on February 26, 2021, March 1, 2021, March 5, 2021 and March 15, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency transport (A0427), and the ground mileage (A0425) provided on October 19, 2020.
You asked the Plan to pay for the ambulance services. You say that the services were provided based on ambulance criteria. You also say that the diagnosis for transport to the emergency room is not related to the enrollee's hospice care. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked.
The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on October 16, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the emergency transport (A0427), and the ground mileage (A0425) provided on October 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve back fusion surgery.
You asked the Plan to pre-approve back fusion surgery. You say that you have back pain. The Plan denied your request. The Plan says the requested services are not medically necessary.
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 back fusion surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have back pain which radiates to the lower extremity. The MRI only shows mild narrowing of the neuroforamina at L3-4 above the previous fusion. There is no instability at L3-4. L3-4 decompression and fusion are not medically needed. Therefore, you do not meet criteria for the requested services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of back fusion surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve back fusion surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and an incisional
biopsy of oral tissue (D7286) provided on February 12, 2021.
You asked the Plan to pay for a comprehensive oral evaluation, and an incisional biopsy of oral tissue. You say
that you were referred to this provider and you want the Plan to pay for the services.
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 comprehensive oral evaluation, and an incisional biopsy of oral tissue 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 comprehensive
oral evaluation (D0150), and an incisional biopsy of oral tissue (D7286) provided on February 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve elevating leg rests (K0195) for the enrollee.
You asked the Plan to pre-approve the leg rests. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of a musculoskeletal condition or the presence of a cast or brace which prevents 90-degree flexion at the knee, severe and significant edema of the lower extremities, or a reclining feature on the wheelchair.
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 leg rests. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not indicate a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee; or significant edema of the lower extremities that requires an elevating leg rest; or that the enrollee has a reclining back on the wheelchair.
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 leg rests have not been met. Therefore, we decided that the Plan does not have to pre-approve elevating leg rests (K0195) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the repair of brow ptosis (67900).
You asked the Plan to pre-approve the repair of brow ptosis. You say that this surgery is medically necessary. The Plan denied your request. The Plan says the requested surgery should be considered cosmetic and not eligible for coverage.
The Plan follows Medicare rules. Medicare rules say that brow ptosis repair, in addition to blepharoplasty and/or blepharoptosis repair, may be necessary in some cases to provide an adequate functional result 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 repair of brow ptosis. Our reviewer says that the requested surgery is not medically necessary and reasonable. Our physician reviewer found that the record indicates that you have dermatochalasis. The record does not contain photographs. The provided record does not indicate why a blepharoplasty would not be sufficient for the treatment of your condition. The elements of the coverage criteria are not satisfied. 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 repair of brow ptosis have not been met. Therefore, we decided that the Plan does not have to pre-approve the repair of brow ptosis (67900).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the keytruda (J9271).
You asked the Plan to pre-approve the keytruda. You say that the drug is medically necessary. The Plan denied your request. The Plan says the member is enrolled in a clinical trial.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. In this case, you asked the Plan to pre-approve the keytruda as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve the keytruda (J9271).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network
provider on March 4, 2021.
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 services provided to the enrollee by an out-of-network
provider on March 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituximab (J9312).
You asked the Plan to pre-approve Rituximab. The Plan denied your request. The Plan says the Plan was unable to determine that Ruxience, the preferred medication, did not work, was not tolerated, or is not a treatment option for the enrollee.
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 Rituximab. Our reviewer says that Rituximab (J9312) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the Plan requires a trial of drug Ruxience before they will approve the requested drug. Our reviewer found that the enrollee has not tried and failed the required drug. Our physician reviewer also found that there is no documentation provided indicating that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Rituximab have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituximab (J9312).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on April 2, 2020 by an out-ofnetwork
provider.
You asked the Plan to pay for the office visit. You say that the enrollee was treated for acute problems so you
would like the Plan to reconsider the claim for payment. The Plan denied your request. The Plan says prior
authorization was not obtained as required.
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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for the service. Therefore, we decided that the Plan does not have to pay for the office visit provided on April 2, 2020 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Test strips (CPT code A4253), for the enrollee.
You asked the Plan to pre-approve the strips. You say that the strips are medically necessary. The Plan denied your request. The Plan says there was no documentation provided to support the medical necessity of a non LifeScan product.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the strips have not been met. There was no documentation provided to support the medical necessity of a non LifeScan product. Therefore, we decided that the Plan does not have to pre-approve Freestyle Test strips (CPT code A4253), for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided by a participating provider on February 24, 2021.
You asked the Plan to waive the copayment for a CT scan. You say that you would like this copayment waived. 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 $250 copayment for outpatient diagnostic tests/in-network/advanced imaging service. You have been asked to pay a $233.52 which is less than your copayment amount of $250 for a CT scan. A CT scan falls within the outpatient diagnostic tests/in-network/advanced imaging service 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 CT scan provided by a participating provider on February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99215) rendered by the out-of-network (OON) provider on March 5, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99215) rendered by the out-of-network (OON) provider on March 5, 2021.