Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the palliative emergency treatment of dental pain (D9110) provided on August 4, 2021.

You asked the Plan to pay for the dental service. You say that part of your molars had broken off. You say that you went to your dentist of many years to assess the situation. You say that you were referred to an oral surgeon to have the remaining tooth extracted. You also say that you feel that your coverage should be more complete. The Plan denied your request. The Plan says palliative emergency treatment of dental pain is not listed as a covered service. The Plan also says that you did not contact them prior to receiving the services to verify 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, the palliative emergency treatment of dental pain is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the palliative emergency treatment of dental pain (D9110) provided on August 4, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the abdominal paracentesis provided on February 17, 2021.  You asked the Plan to pay for the abdominal paracentesis. You say that you attached the letter of revocation and the claim should be processed for payment. The Plan denied your request. The Plan says Original Medicare is responsible for payment.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  The enrollee ended Medicare Hospice benefits on February 1, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the abdominal paracentesis provided on February 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on June 24, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the genetic testing. You say that the genetic testing must be covered because the service is covered by original Medicare. The Plan denied your request. The Plan says no prior authorization was obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on June 24, 2021, by an out-of-network (OON) provider.
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.  You asked the Plan to pre-approve IRF care. 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 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.    Our physician reviewer found based on the medical records provided there is no documentation that the enrollee requires the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be appropriate 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 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services received on June 22, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic services received on June 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from August 2, 2019 to August 7, 2019.  You asked the Plan to pay for acute inpatient hospital care. You say that this should be paid for. The Plan denied your request. The Plan says the DRG was adjusted.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   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 pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found though elevated WBC and hypotension were noted upon presentation, these values promptly improved with treatment in the emergency department. There is no evidence of significant physiologic instability. The review has determined that the records did not support the DRG and diagnosis codes billed 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from August 2, 2019 to August 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses purchased on May 6, 2021.

You asked the Plan to pay for the glasses. You say that customer service told you that you could buy the glasses anytime within the year of 2021. The Plan denied your request. The Plan says this service is limited to one pair every two years.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers eyeglasses once every two years. 

We looked at the file and the Plan's rules. The file shows that eyeglasses were last received in December 2019. The glasses would not be reimbursed again until December 2021. Based on this information, we decided that the Plan's rules for coverage of the glasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses purchased on May 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Topotecan Hydrochloride, Methotrexate Sodium, and Cytarabine, with supporting drugs Ondansetron, Dexamethasone, and Lorazepam.  You asked the Plan to pre-approve the requested drugs. The Plan denied your request. The Plan says the drug regimen is not being prescribed for a medically accepted indication.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 the requested drugs. Our physician reviewer found that the enrollee has recurrent glioblastoma. The requested use of the drug regimen is not FDA-approved for the enrollee's diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The use is not listed as not indicated, not supported, or not recommended in any of the compendia. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested drugs have not been met. Therefore, we decided that the Plan does not have to pre-approve Topotecan Hydrochloride, Methotrexate Sodium, and Cytarabine, with supporting drugs Ondansetron, Dexamethasone, and Lorazepam.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428), and ground mileage (A0425) provided on February 24, 2021.  You asked the Plan to pay for the ambulance services. You say that the enrollee was not enrolled in hospice at the time of transport. You say that hospice became effective after the transport was provided. You also say that this claim should be paid. 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. The hospice benefit starts on the date of election and is not time specific. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428), and ground mileage (A0425) provided on February 24, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99053) provided April 21, 2021.

You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed cannot be paid separately.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT code 99053 is not supported in the medical record. Specifically, per the National Physician Fee Schedule, this code has a status of "B" and payment is bundled into the primary procedure (99284). Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99053) provided April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).  You asked the Plan to pre-approve RFA. 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 follows Medicare rules. Medicare rules say that the thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet joint (medial branch) nerves are considered medically reasonable and necessary when specific criteria are met.  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. Our reviewer says that the services are not medically necessary. Our physician reviewer found the LCD is clear in that it requires six months of pain relief after an RFA. This was not achieved. Therefore, at this time, 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 RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve medical nutrition therapy.  You asked the Plan to pre-approve medical nutrition therapy services. You say that this is medically necessary. The Plan denied your request. The Plan says this service is authorized for beneficiaries who have diabetes or renal disease.  The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes.   Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does not have to pre-approve medical nutrition therapy.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing provided on August 24, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the drug testing. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.    The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent.  Therefore, we decided that the Plan does not have to pay for the drug testing provided on August 24, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on June 8, 2021.

You asked the Plan to waive the copayment for the office visit. You say that the doctor was late and did not see you in the office. 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 $10 copayment for an in-network primary care visit for Medicare-covered services.

You have been asked to pay a $10 copayment for the office visit. The office visit falls 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. The medical record shows you were seen by the provider in the office. Therefore, we decided that the Plan does not have to waive the copayment for the office visit provided on June 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Opdivo, carboplatin, and paclitaxel.  You asked the Plan to pre-approve Opdivo, carboplatin, and paclitaxel. 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 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 Opdivo, carboplatin, and paclitaxel. Our reviewer says that the services are not medically necessary. Our physician reviewer found the review indicates that the documentation does not support that the Opdivo, Carboplatin, Paclitaxel is medically reasonable and necessary for you. The documentation does not support that the Opdivo, Carboplatin, Paclitaxel is safe and effective 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 Opdivo, carboplatin, and paclitaxel have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo, carboplatin, and paclitaxel.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the dental services provided by an out-of-network provider on February 3, 2021.  You asked the Plan to pay for the dental services. You say that the provider was previously in-network and the procedures should be covered. The Plan denied your request. The Plan says dental services are only covered when received by a participating provider.  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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services provided by an out-of-network provider on February 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 11, 2021.

You asked the Plan to pay for the laboratory services. 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. 

The laboratory 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 laboratory services provided on March 11, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for physical therapy provided by an out-of-network provider on June 11, 2021.  You asked the Plan to pay for out-of-network physical therapy. You say that the office, individual provider and the referring provider are participating providers with Medicare. You say that the therapist treated the member in good faith with the medical care required and payment should be approved. The Plan denied your request. The Plan says prior authorization for out-of-network services was not obtained.   Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for physical therapy provided by an out-of-network provider on June 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the visual field examination provided by an out-of-network provider on August 10, 2021.  You asked the Plan to pay for the visual field examination. You say that the primary care physician is not an eye doctor and requesting an approved referral is ridiculous. You say that this was necessary, and the Plan should pay the balance. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not approved in advance.    Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the visual field examination provided by an out-of-network provider on August 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted molecular pathology procedure provided on March 17, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the unlisted molecular pathology procedure. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent.

Therefore, we decided that the Plan does not have to pay for the unlisted molecular pathology procedure provided on March 17, 2021, by an out-of-network (OON) provider.