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

We decided that the Plan does not have to pay for the laboratory services provided on January 30, 2020, to
February 27, 2021, by an OON provider.
You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services
received were neither emergent nor urgent and prior authorization was not obtained to seek out-of-network
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 laboratory services provided on January 30,
2020, to February 27, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the therapeutic phlebotomy provided on April 22, 2021.
You asked the Plan to waive the copayment for the therapeutic phlebotomy. You say that the code (99195) was used incorrectly. You say the claim should be processed as an outpatient laboratory service. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment for each covered surgery or observation room service in an outpatient hospital. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the standard $275 copayment for the therapeutic phlebotomy.
You have been asked to pay a $104.09 copayment for the therapeutic phlebotomy. The therapeutic phlebotomy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows that the therapeutic phlebotomy is considered a separate medical service.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the therapeutic phlebotomy provided on April 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided o May 24, 2021.

You asked the Plan to pay for these services. You say that you did not know this provider was not in network
The Plan denied your request. The Plan says you did not have prior authorization for out of network 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 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 out of network
physician services provided o May 24, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 home health physical therapy (PT) visits.
You asked the Plan to pre-approve 8 home health PT visits. 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. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 8 home health PT visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee is walking household distances. The enrollee is mobile with minimal supervision. The enrollee appears to be functioning such that ongoing PT can be provided via a home exercise program or outpatient therapy. As such, the requested, ongoing, home health PT is not shown to be medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 8 home health PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 home health physical therapy (PT) visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment lab services (80061, 80076, 36415) provided May 24, 2021.
You asked the Plan to waive the copayment the lab services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct 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 $45 copayment for lab services. You have been asked to pay the allowable amount of $11.39 for the lab services. The allowable amount is less than the $45 copayment listed in the Evidence of Coverage. 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 lab services (80061, 80076, 36415) provided May 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on December 17, 2020.

You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility.

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 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 subsequent nursing facility care provided on December 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve left knee genicular nerve block (64640).
You asked the Plan to pre-approve left knee genicular nerve block. You say that this request is medically necessary. The Plan denied your request. The Plan says the requested procedure is investigational and therefore not covered.
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 left knee genicular nerve block. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental investigational approach. The requested procedure is currently the subject of ongoing clinical trials. Therefore, the request is deemed 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 left knee genicular nerve block have not been met. Therefore, we decided that the Plan does not have to pre-approve left knee genicular nerve block (64640).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care represented by code 99232 provided on April 18, 2021.
You asked the Plan to pay for code 99232. 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 as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Review of the claim shows that the provider billed, I65.23 - Occlusion and stenosis of bilateral carotid arteries and I65.29 - Occlusion and stenosis of unspecified carotid artery. According to the ICD-10-CM on laterality, this claim has been billed with mismatched/conflicting diagnosis codes. It is not appropriate to report unspecified, or left and right diagnosis codes when a more specific code is available. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care represented by code 99232 provided on April 18, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Onpattro.

You asked the Plan to pre-approve Onpattro. You say that the drug is being prescribed to treat the enrollee's
hTTR related polyneuropathy. The Plan denied your request. The Plan says that studies have not proven the
drug helpful for the enrollee's condition when used with Vyndamax.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved
drugs if they are medically accepted as safe and effective or appropriate for the particular use.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Onpattro. Our physician reviewer found
that the enrollee has amyloid cardiomyopathy and hereditary TTR polyneuropathy. The requested use of the
drug is FDA-approved for use in the management/treatment of hereditary TTR polyneuropathy. The use is not
listed as not indicated, not supported or not recommended in any of the compendia. The requested drug
generally has been shown to be effective for use in hereditary TTR polyneuropathy (hTTR polyneuropathy).
While, it is noted that the member is also on Tafamidis Meglumine (Vyndamax), this drug is only FDA
approved for use in cardiac symptomology associated with hTTR. There is not a reason to otherwise conclude
that the use of the two drugs together would present a safety concern. In as much, the requested drug can be
considered 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 Onpattro have been met. Therefore, we decided that the Plan has to pre-approve
Onpattro.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pin retention (D2951), resin-based composite (D2393), and palliative treatment (D9110), provided on May 6, 2021, and May 18, 2021.
You asked the Plan to pre-approve the dental services. You say that the services were medically necessary. The Plan denied your request. The Plan says you exhausted your Plan benefit for fillings and the pin retention and palliative treatment are not covered services under your Plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Specifically, you have exhausted your Plan benefit for filling and the pin retention and palliative treatment are not covered services under your supplemental dental Plan.
Therefore, we decided that the Plan does not have to pre-approve the pin retention (D2951), resin-based composite (D2393), and palliative treatment (D9110), provided on May 6, 2021, and May 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the insulin provided on April 7, 2021.

You asked the Plan to pay for the insulin. You say that you were advised that you used Victoza for your
diabetes but were told that you would be receiving an insulin injection instead. The Plan denied your request.
The Plan says insulin is a self-administered drug and is not covered under your plan.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the insulin provided on April 7,
2021.

Benefits for the insulin may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation provided on May 20, 2021.

You asked the Plan to pay for the comprehensive oral evaluation (D0150). You say that the dental work should be covered since is the only dental work you have had for 2021. The Plan denied your request. The Plan says the comprehensive oral evaluation is only covered every 3 years.

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 record shows you had this procedure in 2019. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation provided on May 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee does not appear to be able to tolerate the minimum three hours of therapy daily that is required in an inpatient rehabilitation facility.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.

The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a stroke. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on December 17, 2019.
You asked the Plan to pay for the anesthesia services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the corrected claim was not submitted timely per Medicare guidelines.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the anesthesia services was not filed until June 4, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on December 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays
(D0274), fluoride treatment (D1206) and periodontal maintenance (D4910) provided on March 22, 2021.
You asked the Plan to pay for the dental services. You say that these services were necessary and should be
covered. The Plan denied your request. The Plan says they have agreed to cover the full allowed cost for these
services; however, you used an out-of-network provider who billed an amount greater than this allowed cost,
and you are responsible for the difference between what the provider billed and what the Plan pays.
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 pays only up to a
certain amount for each covered supplemental dental service. If you choose to see an out-of-network provider,
you might be billed for any amount greater than what the Plan pays.
The provider billed the Plan $298 for the dental care provided on March 22, 2021. The Plan's total allowed
amount for the services provided is $143. This is the full payment that the Plan is able to make for these
services, and this is the amount that an in-network provider would accept as full payment for these services.
However, out-of-network providers do not have this agreement and are allowed to bill you for the remaining
cost. The provider you used is not part of the Plan's dental network, so you may be asked to pay up to $155
($298 - $143 = $155) for the services. 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 pay for the periodic oral evaluation (D0120),
bitewing x-rays (D0274), fluoride treatment (D1206) and periodontal maintenance (D4910) provided on March
22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (CPT code 99214) provided
on May 25, 2021.
You asked the Plan to waive the copayment for the office visit. You say that this was a brief discussion with
the doctor about past medical problems and issues. The Plan denied your request. The Plan says the claim was
processed accordingly with your 2021 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file shows that you received office services on May 25, 2021. You were asked to pay a $20
copayment for the office visit. Per your contract enrollees must pay a $20 copayment for each primary care
physician's office visit. This means that you have been asked to pay the correct amount based on your contract
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the copayment for the office visit (CPT code
99214) provided on May 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on August 25, 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. You say that these services were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained for these services. The Plan says that the member's primary care physician did not refer 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 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 August 25, 2020 by an out-of-network (OON) provider
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that you need continued therapy. The Plan denied your
request. The Plan says rules for SNF care have not been met because the requested level of care is not
medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found that you have no identifiable skilled nursing
service needs or skilled therapy service needs. You do not require skilled nursing or therapy services on a daily
basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled
nursing facility setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve SNF care.