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

We decided that the Plan does not have to pre-approve a follow-up visit to be provided by an out-of-network
provider.
You asked the Plan to pre-approve an office visit with an out-of-network provider. You say that you do not
trust going to a new physician with the concern of the area of your body. The Plan denied your request. The
Plan says the service is available within the primary network.
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 services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a followup
visit to be provided by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the continuation of skilled services can be provided on an intermittent
basis on an outpatient basis, in a long-term care facility, or at the home with home health care services.
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 services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for SNF services.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia; Injection, denosumab, 1 mg (J0897). You say that the enrollee is a high fracture risk and cannot take oral bisphosphonates. The Plan denied your request. The Plan says the enrollee has not tried and failed zoledronic acid nor has a history of osteoporotic fracture.
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 Prolia; Injection, denosumab, 1 mg
(J0897). Our reviewer says that the drug is not medically reasonable and necessary. Our physician reviewer
found the enrollee has not tried and failed the required drug. There is no documentation provided indicating
that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee.
The enrollee does not have a history of an osteoporotic fracture.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia; Injection, denosumab, 1 mg (J0897) have not been met. Therefore, we
decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found you have lumbar spinal stenosis. The
requested Superion spacer is considered experimental in nature, as more research is needed to show safety and
efficacy. The services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a Vertiflex Superion spacer.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a urine polymerase chain reaction (PCR) panel (87799,
87798, 87150, 87482) provided on March 24, 2021.
You asked the Plan to pay for a urine PCR panel. You say that some of the testing performed is quantifiable
and it is faster than traditional testing. The Plan denied your request. The Plan says this testing is not supported.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. The rules also say for Medicare to consider coverage and payment for any item or
service, the information submitted by the supplier or provider must corroborate the documentation in the
beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.
We looked at the file and Medicare rules. The submitted medical records do not include information showing
why these tests were ordered. Without this information, the medical necessity of this testing cannot be verified.
Based on this information, we decided that Medicare rules for coverage of a urine PCR panel have not been
met. Therefore, we decided that the Plan does not have to pay for a urine polymerase chain reaction (PCR)
panel (87799, 87798, 87150, 87482) provided on March 24, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating
provider on June 14, 2021.
You asked the Plan to waive the copayment for lab work. You say that you should not have to pay for the
doctor's mistake. The Plan denied your request. The Plan says the correct copayment has been 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 $5
copayment for outpatient diagnostic tests/lab services.
You have been asked to pay a $5 copayment for lab work. Lab work was provided; therefore, the correct
copayment has been applied. Lab work falls within the outpatient diagnostic tests/lab services 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 lab work provided by a participating provider on June 14,
2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement of subcutaneous tissue (11042) rendered by the out-of-network (OON) provider on April 30, 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 debridement of subcutaneous tissue (11042) rendered by the out-of-network (OON) provider on April 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 12, 2021.
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 billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on January 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the inpatient physician care provided from September 24, 2020, to October 7, 2020.

You asked the Plan to waive the deductible for the inpatient physician services. You say that you are appealing these claims. 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. Your contract with the Plan says that there is a $198 deductible and a $1,408 deductible that applies towards in-network inpatient physician services. .

The inpatient physician services you asked the Plan to waive the deductible for fall within the "Inpatient Hospital Care" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $198 deductible and a $1,408 deductible that applies towards in-network inpatient physician services. This cost sharing is a contractual obligation that had not been met at the time the inpatient physician services were received on September 24, 2020 to October 7, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the inpatient physician care provided from September 24, 2020, to October 7, 2020.
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 you are appealing based on medical necessity. The
Plan denied your request. The Plan says the denial of authorization for IRF service is correct.

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 the complexity of your nursing, medical, and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you may need
physical and/or occupational therapy, there is no documented need for an intensive rehabilitation therapy
program. There is not a reasonable expectation that you will be able to fully participate in - and benefit from -
the intensive rehabilitation therapy program provided in an IRF.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a polyurethane liner for a power wheelchair.
You asked the Plan to pre-approve polyurethane liner. You say that with your current seat you cannot use your wheelchair all the time, due to having to machine-wash the seat cover in order to keep it sanitary. The Plan denied your request. The Plan says the denial of authorization for this accessory is correct, because this item is not primarily medical in nature and is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a polyurethane liner for a power wheelchair.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the genetic testing provided on March 10, 2021.

You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says that the testing was not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the testing services. Our physician reviewer found that the enrollee has acute lymphoblastic leukemia (ALL). According to the National Comprehensive Cancer Network (NCCN) guidelines for ALL, next generation sequencing is recommended, particularly in Philadelphia chromosome negative to aid in classification and treatment. Therefore, the testing was medically reasonable and necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing services have been met. Therefore, we decided that the Plan has to pay for the genetic testing provided on March 10, 2021.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the spinal injection procedure you had at an outpatient hospital facility on April 28, 2021.
You asked the Plan to waive the copayment for the spinal injection procedure. You say that you believe the wrong procedure was performed, so you should not have to pay a copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $350 copayment for outpatient surgery in an outpatient hospital facility.
You have been asked to pay a $350 copayment for the spinal injection procedure. The spinal injection procedure falls within the outpatient surgery in an outpatient hospital facility benefit category. The medical records show that your doctor signed off on the actual procedure performed. 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 spinal injection procedure you had at an outpatient hospital facility on April 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on May 11, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that there is no referring provider.
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 physician services provided on May 11, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a radiofrequency ablation (RFA) procedure.

You asked the Plan to pre-approve RFA procedure. You say that the enrollee received 50-60% pain relief from both modalities of previous radiofrequency ablation. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because repeat thermal facet joint radiofrequency ablation is not appropriate in this clinical scenario.

The Plan follows Medicare rules. Medicare rules state that repeat thermal facet joint RFA is considered medically reasonable and necessary only after at least 6 months of improvement in pain or improvement in the ability to perform previously painful movements and activities of daily living. 

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 procedure. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested repeat radiofrequency ablation (RFA) procedure. Our physician reviewer found this request is for a repeat RA procedure to the same region less than 6 months after the prior procedure.

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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a radiofrequency ablation (RFA) procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy (D3310).

You asked the Plan to pre-approve endodontic therapy. You say that the service is necessary. The Plan denied
your request. The Plan says the service at issue is not a covered benefit.

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. Therefore, we decided that the Plan does not have to pre-approve
endodontic therapy (D3310).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pontics (D6240) for tooth #'s 12, 13, 14, and 15 and retainer crowns (D6750) for tooth #'s 11 and 16.
You asked the Plan to pre-approve the pontics and retainer crowns. You say that you need the bridge. The Plan denied your request. The Plan says the requested six-unit posterior fixed bridge is beyond the scope of benefit coverage.
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 pontics and retainer crowns when the services are medically necessary and reasonable. 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 pontics and retainer crowns. Our reviewer says that the criteria for a fixed bridge has not been met. Our physician reviewer found the span of the bridge is very long, and the terminal abutment #11 has been endodontically treated and has a support post. An endodontically treated tooth is a poor terminal abutment due to risk of fracture. Our reviewer found that the crown to root ratio for the long span bridge is poor, with two teeth replacing four missing teeth. Our physician reviewer also found that given the poor restorative scenario presented with a long span and an endodontically treated terminal abutment, there would be no medical necessity for the requested procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the pontics and retainer crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve pontics (D6240) for tooth #'s 12, 13, 14, and 15 and retainer crowns (D6750) for tooth #'s 11 and 16.