Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) provided on April
9, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that authorization was not obtained
prior to this enrollee being seen because it is the nursing facility's responsibility to get authorization for their
patients. You also say that it was medically necessary for the enrollee to receive the treatment that was
provided, and you did not know the facility failed to obtain a pre-authorization. The Plan denied your request.
The Plan says this service was rendered by an OON provider. The Plan also says that prior authorization 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 the domiciliary or rest home visit (99336)
provided on April 9, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Solaire Adjustable King mattress, Lineal Adjustable bed base (twin XL) and the Saatva Luxury Organic Mattress pad (E0625), purchased on May 31, 2021.
You asked the Plan to pay for the Solaire Adjustable King mattress, Lineal Adjustable bed base (twin XL) and the Saatva Luxury Organic Mattress pad. You say that the items are medically necessary. The Plan denied your request. The Plan says these are not covered items.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pay for the Solaire Adjustable King mattress, Lineal Adjustable bed base (twin XL) and the Saatva Luxury Organic Mattress pad (E0625), purchased on May 31, 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.
You asked the Plan to pre-approve IRF care. You say that you need these services in order to regain maximum body function again. The Plan denied your request. The Plan says that your needs can be met at a lower level of care.
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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for chest pain, esophageal perforation and replacement of esophageal stent. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 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. Our physician reviewer found that your 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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the grafting of autologous fat (15773) provided on July 15,
2021.
You asked the Plan to pay for the grafting of autologous fat (15773). You say that the procedure is medically
necessary based on the member's condition, medical history, and clinical assessment. You say that supporting
documentation is attached and the claim should be paid immediately. The Plan denied your request. The Plan
says cosmetic procedures are not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. Medicare rules say that cosmetic surgery and related services, except as required for
the prompt repair of accidental injury or to improve the functioning of a malformed body member, 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 pay for the grafting of autologous fat (15773). Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found that the documentation in the case file is insufficient to support that the
autologous fat graft was medically reasonable and necessary for the enrollee 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 the grafting of autologous fat (15773) have not been met. Therefore, we decided
that the Plan does not have to pay for the grafting of autologous fat (15773) provided on July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99336) rendered by the out-of-network (OON) provider on August 17, 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 domiciliary or rest home visit for the evaluation and management of an established patient (99336) rendered by the out-of-network (OON) provider on August 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) coded 70450 provided on May 3, 2021.

You asked the Plan to pay for the CT. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 is a column II code to column I code 70796. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) coded 70450 provided on May 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a Foundation Pain Index (0117U) provided on June 17, 2021.
You asked the Plan to pay for a Foundation Pain Index. You say that this was medically necessary. The Plan denied your request. The Plan says this was experimental.
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 pay for a Foundation Pain Index. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found these tests are considered experimental. Their value has not been demonstrated.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Foundation Pain Index have not been met. Therefore, we decided that the Plan does not have to pay for a Foundation Pain Index (0117U) provided on June 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the excessive skin and subcutaneous tissue excision
(15847).
You asked the Plan to pre-approve the excessive skin and subcutaneous tissue excision (15847). The Plan
denied your request. The Plan says if medical necessity criteria are not met, the procedure would be considered
cosmetic and cosmetic surgery is an exclusion of your plan benefits.
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 excessive skin and subcutaneous
tissue excision (15847). Our reviewer says that the requested items/services are not considered medically
reasonable and necessary in this case. Our physician reviewer found that an abdominoplasty is not considered
medically reasonable and necessary for the treatment of illness or injury or to improve the function of a
malformed body member for the enrollee 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 the excessive skin and subcutaneous tissue excision (15847) have not been met.
Therefore, we decided that the Plan does not have to pre-approve the excessive skin and subcutaneous tissue
excision (15847).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories.
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 enrollee does not have a qualifying diagnosis causing mobility limitation for which a K0849 group 3 power wheelchair is medically needed.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 medically reasonable or necessary. Our physician reviewer found based on the medical records provided, your mobility limitation is primarily due to chronic low back pain, bilateral hip pain, bilateral leg weakness and pain, unsteady gait, shortness of breath and dyspnea on exertion rather than due to a neurological condition, myopathy or congenital skeletal deformity. As you do not meet criteria for the requested group 3 power wheelchair base, the associated requested accessories also do not meet Medicare criteria for coverage. 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 a group 3 power wheelchair and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI)
joint.
You asked the Plan to pre-approve RFA of the SI joint. You say that this is medically necessary for the
enrollee's condition. The Plan denied your request. The Plan says the requested procedure is
experimental/investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve RFA of the SI joint. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found this is considered an experimental/investigational procedure because of the wide
variation of efficacy reported in the literature. 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 RFA of the SI joint have not been met. Therefore, we decided that the Plan does
not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiographic monitoring and analysis (93270, 
93271) rendered by the out-of-network (OON) provider on August 9, 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 electrocardiographic monitoring and analysis (93270, 93271) rendered by the out-
of-network (OON) provider on August 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (J9271).

You asked the Plan to pre-approve Keytruda. You say that Keytuda is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met.

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 Keytruda. Our reviewer says that 
Keytruda is not medically necessary. Our physician reviewer found immunotherapy has shown poor responses 
in ovarian cancer. The use of Keytruda in this application is not supported by the Medicare-approved 
compendia or in the medical literature.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda (J9271).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on July 31, 2021.

You asked the Plan to pay for ambulance response and treatment, no transport. You say that the services were medically necessary. 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 July 31, 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 response and treatment, no transport (A0998) provided on July 31, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray exam of the neck and spine (72040) provided on June 17, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for an x-ray exam of the neck and spine. You say that you say that you are appealing with supporting records. The Plan denied your request. The Plan says this provider is not a network provider with the Plan, and the referral was not authorized by the primary care provider (PCP). The Plan also says that they have also determined that these services are not urgent or emergent, nor were they 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 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 an x-ray exam of the neck and spine (72040) provided on June 17, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 21,
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 the provider did not bill as required by Medicare coding regulations.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70554
is a column II code to column I code 70551. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for imaging services provided to the enrollee on September 21,
2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve SNF services. You say that you need SNF services. The Plan denied your request. The Plan says that there are in network providers who are able to provide 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 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 skilled nursing facility (SNF) services to be provided by an out-of-network (OON) provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on April 22, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for drug testing. You say that you say that you are appealing with supporting records. The Plan denied your request. The Plan says this facility is a non-participating provider, and the referring provider involved in these services is also non-participating. The Plan also says that they did not authorize any services for these providers.
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 drug testing (G0483) provided on April 22, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the bitewing x-rays (D0274), initial 
periapical x-ray (D0220), additional periapical x-rays (D0230 x 5), oral exam (D0120), and prophylaxis 
(D1110) provided on January 21, 2021.

You asked the Plan to pay an additional amount for the dental services. You say that documentation from the 
plan indicates that you have a $0 copay for dental cleaning in an out of network. You say that you feel the plan 
should cover 100% of the bill. You also say that you were never told the provider was out of network. The Plan 
denied your request. The Plan says the provider in this case is out of network. 

The Plan also says that out of network providers are allowed to balance bill members for the difference 
between their billed amount and the plans paid amount.

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 providers may bill you 
for any amount greater than what the plan pays. Therefore, we decided that the Plan does not have to pay an 
additional amount for the bitewing x-rays (D0274), initial periapical x-ray (D0220), additional periapical x-rays 
(D0230 x 5), oral exam (D0120), and prophylaxis (D1110) provided on January 21, 2021