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

 We decided that the Plan does not have to pay for the laboratory service (88305) rendered by the out-of-network (OON) provider on July 6, 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 laboratory service (88305) rendered by the out-of-network (OON) provider on  July 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for anesthesia services provided on May 30, 2021.  You asked the Plan to pay for the services provided. You say that denying coverage based on a diagnosis code is a violation of prudent layperson standard. The Plan denied your request. The Plan says primary dental procedures are not covered. Medicare generally does not cover dental services. The Plan follows the same rule.  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. As such, services related to non-covered services are not covered by Medicare or the enrollee's plan. Therefore, we decided that the Plan does not have to pay for anesthesia services provided on May 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a retainer crown (D6740) and pontic (D6245) provided on August 31, 2021.  You asked the Plan to pay for a retainer crown and pontic. You say that you were not previously made aware of the maximum coverage. The Plan denied your request. The Plan says rules for payment have not been met because you have reached the maximum plan benefit for dental services for the 2021 calendar year.  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 dental services up to $1,000 per calendar year.   We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a retainer crown and pontic have not been met. Specifically, the Plan has documented that you have exhausted your dental benefit for the 2021 calendar year. Therefore, we decided that the Plan does not have to pay for a retainer crown (D6740) and pontic (D6245) provided on August 31, 2021.   Your complaint about not being made aware of the maximum coverage for dental services is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve treatment with Synvisc-One.  You asked the Plan to pre-approve Synvisc-One. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been met.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Synvisc-One. Our reviewer says that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the Plan requires a trial of Gel-One and Euflexxa before they will approve the requested drug. The requested drug is a new start. The provided records do not indicate that the enrollee has tried and failed the Plan's preferred step-one alternatives. The record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from, the Plan's preferred step-one alternatives. The elements of the coverage criteria are not satisfied.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Synvisc-One.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (81479) provided June 14, 2021.  You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says this service is not covered.  The Plan must follow Medicare rules. Medicare rules say that genes not identified as having actionable use are not considered reasonable and necessary. The algorithms employed in combinatorial testing are also not currently considered reasonable and necessary components of multi-gene testing.  We looked at the file and Medicare rules. The testing at issue was combinatorial in nature. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81479) provided June 14, 2021.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for WATS 3D biopsy testing provided on November 19, 2020.  You asked the Plan to pay for laboratory testing. You say that the enrollee's treating physician ordered this testing after making a professional determination of medical necessity. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because medical literature and clinical practice guidelines do not support the clinical utility of this testing and the pathologist did not document a need for the special stain.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for WATS 3D biopsy testing provided on November 19, 2020.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for admission to a skilled nursing facility (SNF) for the enrollee.  You asked the Plan to pay for the admission. You say that this is medically necessary. The Plan denied your request. The Plan says care is more appropriate for long term care or assisted living.  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 pay for the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided, there is no documentation that the enrollee requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. The enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part time basis appear 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 the admission have not been met. Therefore, we decided that the Plan does not have to pay for admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the laboratory service (88305), the office visit (99203), the repair, complex, of the scalp, arms, and/or legs (13121), and the excision of a benign lesion (11403) rendered by the out-of-network (OON) providers on November 9, 2020.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the services were rendered by an out of network provider, without prior authorization.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan did not provide the 2020 Evidence of Coverage booklet to our organization to determine coverage eligibility. Therefore, we decided that the Plan has to pay for the laboratory service (88305), the office visit (99203), the repair, complex, of the scalp, arms, and/or legs (13121), and the excision of a benign lesion (11403) rendered by the out-of-network (OON) providers on November 9, 2020.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for a CT scan of the head and brain (70450) and a hospital outpatient clinic visit (G0463) provided on April 20, 2021, by an out-of-network provider.  You asked the Plan to pay for a CT scan of the head and brain and a hospital outpatient clinic visit. You say that the requested services were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for out-of-network care have not been met.  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 a CT scan of the head and brain (70450) and a hospital outpatient clinic visit (G0463) provided on April 20, 2021, 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 for the enrollee.  You asked the Plan to pre-approve SNF services. You say that the enrollee is ready to enter a SNF. The Plan denied your request. The Plan says that the enrollee's needs may be met at a lower level of care.  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 the enrollee's 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for deep sedation/general anesthesia (D9222, D9223) and inhalation of nitrous oxide (D9230) provided on August 17, 2021.  You asked the Plan to pay for deep sedation/general anesthesia and inhalation of nitrous oxide. You say that an extraction like the one you had required you to be put under. You also say that no one would want to go through that much pain without anesthesia. You are requesting a portion of this claim is paid. The Plan denied your request. The Plan says the services at issue are 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 pay for deep sedation/general anesthesia (D9222, D9223) and inhalation of nitrous oxide (D9230) provided on August 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array.  You asked the Plan to pre-approve percutaneous implantation of neurostimulator electrode array. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 percutaneous implantation of neurostimulator electrode array. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has bilateral shoulder pain. The enrollee has had supraclavicular nerve blocks that provided temporary relief followed by pulsed radiofrequency ablation of the nerve. The enrollee's magnetic resonance imaging scan shows a full thickness tear of the supraspinous tendon, acromioclavicular arthritis and bursitis. There has been no surgical intervention. The literature supporting this procedure is for post-amputation pain and for post-operative rotator cuff repair, neither of which this enrollee has. This would be an experimental/investigational procedure. Therefore, the enrollee does not meet criteria for the requested 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 percutaneous implantation of neurostimulator electrode array have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (81162, 81206, 81292, 81295) provided on March 25, 2021.  You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the out-of-network services were not emergent or pre-authorized.  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 services 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 these services. Therefore, we decided that the Plan does not have to pay for lab services (81162, 81206, 81292, 81295) provided on March 25, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy evaluation provided by a physical therapist on August 10, 2020.

You asked the Plan to pay for the physical therapy evaluation. You say that plans are required to pay non-contracted providers at the preferred provider rate if services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the code billed.

The Plan must follow Medicare rules. Medicare rules say that services of a physical therapist billed as services incident to a physician/non-physician practitioner's service must meet all incident requirements.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy evaluation have not been met. Specifically, the billing provider is a nurse practitioner. As such, physical therapy services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for the physical therapy evaluation provided by a physical therapist on August 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (81408, 81405, 81407, 81406) provided July 6, 2021.  You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the service at issue is non-covered.  The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all Cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented Cardiovascular disease.  We looked at the file and Medicare rules. The services at issue are cardiovascular testing panels and are non-covered. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81408, 81405, 81407, 81406) provided July 6, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the breast ultrasound you had on February 1, 2021.  You asked the Plan to waive the copayment for the breast ultrasound. You say that this service was not done on February 1, 2021.  You said that you had an ultrasound on August 2, 2021. 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 $35 copayment for x-rays.   You have been asked to pay a $35 copayment for the breast ultrasound. We looked at the medical records from this date of service and they confirm that you did have a breast ultrasound on February 1, 2021. 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 breast ultrasound you had on February 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a wheelchair ramp on February 24, 2021.  You asked the Plan to pay for a wheelchair ramp. You say that your doctor told you needed this wheelchair ramp. The Plan denied your request. The Plan says it does not cover wheelchair ramps because they are not medical in nature.  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 pay for a wheelchair ramp on February 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.  You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.  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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that this device is experimental. More research is needed to show safety and efficacy.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.