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

We decided that the Plan does not have to waive the deductible and coinsurance for services provided on September 26, 2019.You asked the Plan to waive the deductible and coinsurance for the ambulance services. You say that you never had to pay before for ambulance services. The Plan denied your request. The Plan says you have been charged the deductible and coinsurance correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. The contract with the Plan says that there is a $300 deductible and 20% coinsurance for ambulance services. The item or service you asked the Plan to waive the deductible and coinsurance for falls within the benefit category ambulance services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible and 20% coinsurance for ambulance services. This cost sharing is a contractual obligation that has not yet been met. Therefore, we decided that the Plan does not have to waive the deductible and coinsurance for services provided on September 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral hygiene instructions (D1330), the 2D oral or facial photographic image (D0350 x 4), and the unlisted periodontal service (D4999) provided on November 5, 2019 by the out of network provider.You asked the Plan to pay for the oral hygiene instructions, the 2D oral or facial photographic images, and the unlisted periodontal service. You say that you were assured by the office manager that they accepted your plan. You say that you would not have made an appointment if they did not take your plan. You also say that you have no way to pay the amount that your plan will not cover.The Plan denied your request. The Plan says the oral hygiene instructions, the 2D oral or facial photographic images, and the unlisted periodontal service are not listed as covered services. 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 dental services you received are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the oral hygiene instructions (D1330), the 2D oral or facial photographic image (D0350 x 4), and the unlisted periodontal service (D4999) provided on November 5, 2019 by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation (D4921) for all 4 quadrants, and the periodontal scaling and root planing (D4342) for the upper left and lower left quadrants provided on September 23, 2019.
You asked the Plan to pay for the gingival irrigation for all 4 quadrants, and the periodontal scaling and root planing for the upper left and lower left quadrants. You say that the dentist would not administer further services if this procedure was not done in total. The Plan denied your request. The Plan says gingival irrigation is not listed as a covered service. The Plan also says the frequency limit of 1 procedure every 3 years, per quadrant, has been exceeded.
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, gingival irrigation is not among those covered under this benefit. Additionally, the frequency limit for periodontal scaling and root planing has been exceeded. Therefore, we decided that the Plan does not have to pay for the gingival irrigation (D4921) for all 4 quadrants, and the periodontal scaling and root planing (D4342) for the upper left and lower left quadrants provided on September 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora SoClean CPAP Sanitizer and a SoClean Adapter (E1399).You asked the Plan to pay forthe sanitizer and adapter. You say that you are sometimes forgetful in cleaning your machine, and since you bought the SoClean machine your health has improved.The Plandenied your request. The Plan says this is not a covered benefit.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature and do not meet the Medicare definition of DME. Therefore, we decided that the Plan does not have to pay fora SoClean CPAP Sanitizer and a SoClean Adapter (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on September 6, 2019.You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says there is no valid referral for this serviceMedicare rules say that planscan 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 service 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 subsequent nursing facility care provided on September 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay foran ankle-foot orthosis (L1971) provided to the enrollee on August 19, 2019.You asked the Plan to pay fortheorthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This meansthat the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay foran ankle-foot orthosis (L1971) provided to the enrollee on August 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient admission provided from July 22, 2019 to August 12, 2019.You asked the Plan to pay for the inpatient admission. The Plan denied your request. The Plan says the enrollee must receive care from a network facility. In most cases care received from an out-of-network facility will not be covered.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 servicesat 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 an inpatient admission provided from July 22,2019 to August 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dermatology services provided on September 3, 2019 by an out of network (OON) provider.You asked the Plan to pay for dermatology service. You say that you called a lot of dermatologists but only one was taking new patients.The Plan denied your request. The Plan says several physicians are all in-network providers who could have provided 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 has network providers available who can provide 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 dermatology services provided on September 3, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for services provided on May 15, 2019.You asked the Plan to pay for the ambulance services. You say that the Plan should pay this claim. The Plandenied your request. The Plan says that that the Plan denied for PPG/Hospital Risk.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide information to support their denial. Therefore, we decided that the Plan has to pay for services provided on May 15, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve revision or repair of an operative wound of the eye (66250).
You asked the Plan to pre-approve revision or repair of an operative wound of the eye. 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 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 revision or repair of an operative wound of the eye. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation is insufficient to demonstrate that the requested laser suture lysis is medically reasonable and necessary for the enrollee in this case. Laser suture lysis is considered suture removal. It is inappropriate to code 66250 for laser suture lysis in addition to the surgery, as this is considered an obligatory portion of the postoperative management. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of revision or repair of an operative wound of the eye have not been met. Therefore, we decided that the Plan does not have to pre-approve revision or repair of an operative wound of the eye (66250).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Computed Tomography (CT) scan of the heart (75571).
You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 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 CT scan. Our reviewer says that coverage criteria has not been met. Our physician reviewer found CT scan provides no benefit for patients who are already considered high risk. Calcium scoring is not a covered service. 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a Computed Tomography (CT) scan of the heart (75571).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out-of-network provider on October 7, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollees EOC.
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 has network providers available who can provide 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 by an out-of-network provider on October 7, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveGel-One (J7326).You asked the Plan to pre-approveGel-One (J7326). You say that the requested Gel-One is medically necessary.The Plan denied your request. The Plan says the enrollee must try and fail Orthovisc and Monovisc first.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 Gel-One (J7326). Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee has a diagnosis of Unilateral primary osteoarthritis of the left knee. The Plan requires a trial of drugs Orthovisc and Monovisc first before they will approve the requested drug, Gel-One. In this case, the enrollee has not tried and failed the required drugs. The documentation does not support that Monovisc and Orthovisc (Hyaluronic acid) would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gel-One (J7326) have not been met.Therefore, we decided that the Plan does not have to pre-approveGel-One (J7326).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage and ambulance service, including basic life support and emergency transportation, provided on October 19, 2019.You asked the Plan to pay for the transportation services. You say that the enrollee fell. You say that he transported to the hospital for a higher level of 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 enrollee on hospice.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 the ground mileage and ambulance service, including basic life support and emergency transportation, provided on October 19, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve an excision (15832).You asked the Plan to pre-approve the excision. You say that you have loose skin that causes irritation. The Plan denied your request. The Plan says that this service is considered to be cosmetic.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 excision. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found you have functional impairment of the medial thighs from excess soft tissue that has failed typical conservative management. Your functional impairment would likely resolve or significantly improve with medial thighplasty.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 excision have been met. Therefore, we decided that the Plan has to pre-approve an excision (15832). 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a TAP block (64486).You asked the Plan to pre-approve the TAP block. You say that this service is medically necessary. The Plan denied your request. The Plan saysthere is no evidence to use TAP injection for chronic abdominal pain.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 TAP block. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no peer reviewed literature that supports the use of a TAP block for chronic Abdominal pain. This block is commonly used to provide surgical anesthesia and post-operative pain relief. It's use here would be experimental/investigational.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 TAP block have not been met. Therefore, we decided that the Plan does not have to pre-approve a TAP block (64486).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine transportation.You asked the Plan to pre-approve an exception to the 50 mile limit for routine transportation. The Plan denied your request. The Plan says that the request is not covered by the plan.Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits they are not required to do so. Medicare does not provide exceptions to supplemental benefits.Therefore, we decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine transportation.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT scan of the neck (70490).You asked the Plan to pre-approve the CT scan. You say that this CT Scan is medically necessary. The Plan denied your request. The Plan says the records do not show that a fine needle aspiration (FNA) has been done or the results of the FNA.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 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 CT scan. Our reviewer says that there is no specific clinical rationale for the requested CT study. Our physician reviewer found the requested CT Scan is not medically reasonable and necessary.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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a CT scan of the neck (70490).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthetic agent injections (64402, 64405 and 64450) provided on June 24, 2019.You asked the Plan to pay for anesthetic agent injections. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the operative report did not include documentation of these services.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 64402 is Injection, anesthetic agent; facial nerve.The CPT Code Manual definition of code 64405 is Injection, anesthetic agent; greater occipital nerve.The CPT Code Manual definition of code 64450 is Injection, anesthetic agent; other peripheral nerve or branch.We asked our coder 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 anesthetic agent injections. Our reviewer says that CPT code 64402 does not meet criteria for billing or reimbursement consideration. The medical records provided do not include enough information to corroborate that an Injection, anesthetic agent; facial nerve was performed bilaterally on June 24,2019. CPT code 64405 does not meet criteria for billing or reimbursement consideration.  The medical records provided do not include enough information to corroborate that an Injection, anesthetic agent; greater occipital nerve was performed bilaterallyon June 24, 2019. Our reviewer found CPT code 64450 does not meet criteria for billing or reimbursement consideration.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of anesthetic agent injections have not been met. Therefore, we decided that the Plan does not have to pay for anesthetic agent injections (64402, 64405 and 64450) provided on June 24, 2019.