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

We decided that the Plan does not have to pre-approve an Intracept procedure.
You asked the Plan to pre-approve an Intracept procedure. 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 an Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the intracept procedure is experimental for low back pain (LBP). More research is needed to show safety and efficacy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on April 23, 2021.
You asked the Plan to pay for the ambulance services. You say that because of COVID and emergency room
overload you chose not to be transported to the hospital. The Plan denied your request. The Plan says the
Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service.
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 April 23, 2021. 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 ambulance services provided on April 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on May 18, 2021 by a non-participating provider.
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 the services were rendered by a non-participating 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 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 office visit provided on May 18, 2021 by a non-participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), first intraoral periapical x-ray (D0220), each additional intraoral periapical x-ray (D0230), bitewing x-rays (D0274), prophylaxis (D1110), topical application of fluoride (D1208), and oral hygiene instructions (D1330) provided on June 7, 2021 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation, intraoral periapical x-rays, bitewing x-rays, prophylaxis, topical application of fluoride, and oral hygiene instructions. You say that you would like to appeal these services because you have been using this dentist for years. The Plan denied your request. The Plan says these services were rendered by a non-contracted provider. The Plan also says that services rendered by a provider who is not in-network 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, the requested items or services are not covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), first intraoral periapical x-ray (D0220), each additional intraoral periapical x-ray (D0230), bitewing x-rays (D0274), prophylaxis (D1110), topical application of fluoride (D1208), and oral hygiene instructions (D1330) provided on June 7, 2021 by an OON provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan.
You asked the Plan to pre-approve Hyalgan. 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.
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 Hyalgan. Our reviewer says that the
medication is not medically necessary. Our physician reviewer found in this case, you have not tried and failed
the required drug(s). There is no documentation provided indicating that the plan's required drug(s) would
likely be less effective and/or likely have adverse effects for you.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have
to pre-approve Hyalgan.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management; more than 30 minutes, (99239) provided on October 8, 2020.
You asked the Plan to pay for the evaluation and management service. You say that the services were medically necessary. 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. 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 date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management; more than 30 minutes, (99239) provided on October 8, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for psychotherapy services you received on January 5, 2021.
You asked the Plan to waive the copayment for the psychotherapy services. You say that you do not agree with the copayment amount. The Plan denied your request. The Plan says this copayment was charged correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 copayment for individual or group psychotherapy. You have been asked to pay a $25 copayment for the psychotherapy services. The psychotherapy services fall within the individual or group psychotherapy 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 psychotherapy services you received on January 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar spinal fusion/Intracept procedure for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is not enough proof that shows this procedure is as safe and as effective as other standard treatment options.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is experimental for low back pain. More research is needed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar spinal fusion/Intracept procedure for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria for this benefit was not met.
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for enrollees with an eligible chronic condition. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Specifically, we have confirmed that you do not have one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from
December 23, 2020 to February 18, 2021.
You asked the Plan to pay for home health services. You say that the services were medically necessary. The
Plan denied your request. The Plan says a corrected claim is required before this service can be paid.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, the claim
was submitted with an invalid HIPPS code. No corrected claim was submitted to the plan. Therefore, we
decided that the Plan does not have to pay for the home health services provided to the enrollee from December
23, 2020 to February 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 16, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
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. The test 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 laboratory services provided on October 16, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to hold you harmless for the annual wellness visit (G0439) provided on July 13, 2020.
You asked the Plan to hold you harmless for the annual wellness visit. You say that you would like reconsideration because you should not be held responsible as these services were rendered by different providers who billed the same code. The Plan denied your request. The Plan says that it is your responsibility to consult the EOC to determine benefit information.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for the annual wellness visit by a contract provider. The file does not show that the Plan provided notice that the annual wellness visit would not be covered. Under Medicare rules, this means the annual wellness visit is considered approved by the Plan. Additionally, the Plan has failed to forward any evidence in regards to how the initial service was billed or if it was paid. The record does not show that a previous annual wellness exam was rendered of billed. It is the burden of the Health Plan to substantiate their denial with evidence. This denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to hold you harmless for the annual wellness visit (G0439) provided on July 13, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided on May 10,
2021.
You asked the Plan to waive the copayment for specialist services. You say that you had a bad reaction to the
coronavirus vaccine which caused you to break your wrist. The Plan denied your request. The Plan says the
claims were processed correctly and you are being charged the correct 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 $30
copayment for specialist services.
You have been asked to pay a $30 copayment for specialist services. Specialist services fall within the
physician/practitioner services, including doctor's office visits 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 specialist services provided on May 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services provided by an OTA on March 31, 2021.
You asked the Plan to pay for the occupational therapy services. You say that the claim was denied incorrectly without appropriate review of the medical records. You say that the records should be reviewed, and the claim processed toward necessary payment. The Plan denied your request. The Plan says the records do not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that the services of an OTA shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the occupational therapy service have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for occupational therapy services provided by an OTA on March 31, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 15, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file, the Plan's contract and Medicare rules. If a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one HCPCS codes must be submitted for the panel. If the laboratory assays genes in serial, then the laboratory must submit claims for genes individually. The order by the treating clinician must reflect whether the treating clinician is ordering a panel or single genes, and additionally, the patient's medical record must reflect that the service billed was reasonable and necessary. When more than two codes from this list are submitted for the same beneficiary on the same date of service, the claims processing system will reject every code submitted after the first two services. However, if a lab runs more than two distinct procedural services from this list on a single date of service, then the lab must use the 59 modifier with each additional service billed as an attestation that it is a distinct procedural service. In this case, the medical records provided do not confirm that the labs were billed correctly. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on December 15, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the osseous, osteoperiosteal, or cartilage graft (D7950) provided on
April 2, 2021.
You asked the Plan to pay for the dental service. You say that page 97 of your Evidence of Coverage lists oral
surgery as covered. You say that there is no limitation or exclusion listed for oral surgery. You say that this
service should be covered. The Plan denied your request. The Plan says that the osseous, osteoperiosteal, or
cartilage graft 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. The Plan covers the dental
service when the services are medically necessary and reasonable.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of the dental service have been met. Specifically, the record shows that 2 oral surgery services are
covered per year with a 75% coinsurance when performed out of network. Therefore, we decided that the Plan
has to pay the out of network rate for the osseous, osteoperiosteal, or cartilage graft (D7950) provided on April
2, 2021. The out of network cost share amount still applies.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81401, 81405, 81406) provided June 25, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment panels except for the standard lipid panel for patients with suspected or documented cardiovascular disease. We looked at the file and Medicare rules. This service is not covered under Medicare rules. 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 lab services (81401, 81405, 81406) provided June 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic blood test provided on March 3, 2021.
You asked the Plan to pay for the diagnostic blood test. You say that you would like reconsideration because these CPT codes are all billable and no prior authorization was necessary. The Plan denied your request. The Plan says screening tests are excluded from coverage.
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. The test at issue in this appeal, the diagnostic blood test, 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 diagnostic blood test provided on March 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network oncology provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are network providers available.
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 a referral to an out-of-network oncology provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services coded as 97110, 97140, G0283, 99072 provided on March 30, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the physical therapy services. You say that treatment in your office was directed by a participating provider, which is referred to as Plan directed care, and therefore, should be processed for reimbursement. 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 physical therapy services coded as 97110, 97140, G0283, 99072 provided on March 30, 2021 by an out-of-network (OON) provider.