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

 We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) joint.  You asked the Plan to pre-approve RFA to the SI joint. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have 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 RFA to the SI joint. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found RFA of the lateral sacral branches is considered experimental/investigational because of the wide variation in efficacy reported in the literature. Therefore, the request is considered not medically reasonable or 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 RFA to the SI joint have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) joint.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on June 25, 2021.  You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.  The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.   We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records do not indicate that the services were provided in a laboratory setting. This means that the claim was billed with the incorrect POS code.  Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on June 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for hearing aids (V5050) provided on August 24, 2021, by an out-of-network provider.  

You asked the Plan to pay for hearing aids. You say that you were never informed that you needed approval from the Plan and that a first hearing aid from the same provider was reimbursed as requested. The Plan denied your request. The Plan says rules for payment have not been met because out-of-network care was not authorized by the Plan.  

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids provided by an out-of-network provider only when out-of-network care has been authorized by the Plan.  

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Specifically, the Plan did not authorize out-of-network services at issue in this case. Therefore, we decided that the Plan does not have to pay for hearing aids (V5050) provided on August 24, 2021, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (72040) provided on September 10, 2021.  

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.  

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, we have confirmed that code 72040 is a column II code to column I code 72082. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (72040) provided on September 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a positron emission tomography (PET) computed tomography (CT) scan of your heart.  You asked the Plan to pre-approve a PET CT scan of the heart. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have 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 a PET CT scan of the heart. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there was no equivocation of the findings and the rationale/need for cardiac PET has not been articulated by the treating physicians. Absent such documentation of medical necessity the requested cardiac PET scan has not been shown to be clinically 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 a PET CT scan of the heart have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) computed tomography (CT) scan of your heart.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series x-ray (D0210) provided on September 15, 2021.  

You asked the Plan to pay for the complete series x-ray. You say that you were given the number for this dental office by the plan. You say that you were never told to ask for a certain dentist. You also say that you should not have to pay anything. The Plan denied your request. The Plan says complete series x-ray is not listed as a covered 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, the complete series x-ray is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series x-ray (D0210) provided on September 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the molecular genetic testing provided on August 25, 2021.  You asked the Plan to pay for the molecular genetic testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  Review of the file shows that the results of a previous prostate biopsy were provided. In addition, there was no documented significant interval increase in prostate-specific antigen (PSA) level. This means the molecular genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the molecular genetic testing provided on August 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the established patient domiciliary or rest home visit (99336) provided on March 5, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the domiciliary or rest home visit. You say that the services provided were medically necessary and you did not know that the facility failed to get preauthorization for the enrollee. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the established patient domiciliary or rest home visit (99336) provided on March 5, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99203) rendered by the out-of-network (OON) provider on August 12, 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 (99203) rendered by the out-of-network (OON) provider on August 12, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent nursing facility care (99310) provided on March 22, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the subsequent nursing facility care. You say that the rendering physician is a Hospitalist physician with the group and depends upon the hospital staff to verify eligibility and to obtain the proper authorization from the enrollee's insurance company. You also say that the treating provider rendered medically necessary services to the enrollee in good faith. The Plan denied your request. The Plan says there is no referral from a contracted network provider, and there was no authorization by the health plan. The Plan also says that the services rendered are not in association with emergency care.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99310) provided on March 22, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay more for the problem focused limited oral evaluation (D0140), amalgam (D2140), add tooth to an existing partial denture (D5650), and simple extraction (D7140) provided on August 26, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay more for the problem focused limited oral evaluation, amalgam, add tooth to an existing partial denture, and simple extraction. You say that you thought that this treating provider was in-network. The Plan denied your request. The Plan says the OON cost share was applied correctly per your plan benefits.  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 are responsible for the difference between the billed amount and allowed amount because these services were received OON. Therefore, we decided that the Plan does not have to pay more for the problem focused limited oral evaluation (D0140), amalgam (D2140), add tooth to an existing partial denture (D5650), and simple extraction (D7140) provided on August 26, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Euflexxa.  You asked the Plan to pre-approve Euflexxa. You say that the enrollee has osteoarthritis on the knee. The Plan denied your request. The Plan says there is no documentation of osteoarthritis other than the clinical diagnosis.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Euflexxa. Our physician reviewer found that in this case, the record indicates the enrollee has knee pain. The provided records do not include radiographs that demonstrate osteoarthritis. The elements of the coverage rules are not satisfied. Therefore, the requested service cannot be recommended.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
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 August 12, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the out-of-network 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 August 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for LTACH care. The Plan denied your request. The Plan says the level of care provided in the LTACH setting is more than the enrollee's medical conditions need. The Plan says that the clinical information received do not show that the guidelines for coverage have been met.  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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.  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-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay the in network rate for the additional periapical x-ray (D0230) provided on September 3, 2021.  You asked the Plan to pay the in network rate for the additional periapical x-ray. You say that you were given the name of this dental office by the plan. You say that you were not given a specific location or provider. You also say that if you had known this office was out of network, you would have gone somewhere else. The Plan denied your request. The Plan says 1 periapical x-ray is covered per calendar year. The Plan also says that the frequency limit 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 and periapical x-ray is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for the initial periapical x-ray that you received on the date of service in this case. Therefore, we decided that the Plan does not have to pay the in network rate for the additional periapical x-ray (D0230) provided on September 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on August 26, 2021.  

You asked the Plan to waive the copayment for the outpatient surgery. You say that the surgery was not in an outpatient facility. The Plan denied your request. The Plan says the provider submitted an outpatient hospital claim and the appropriate copayment was 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 $475 copayment for each Medicare-covered outpatient hospital facility visit.     

You have been asked to pay a $475 copayment for the outpatient surgery. Outpatient 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 for an outpatient surgery provided on August 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the 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 does not meet criteria.  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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility.  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-approve long term acute care hospital (LTACH) services.