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

 We decided that the Plan does not have to pay for the drug test (G0480) rendered by the out-of-network (OON) provider on September 8, 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 drug test (G0480) rendered by the out-of-network (OON) provider on September 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug test (G0482) rendered by the out-of-network (OON) provider on June 8, 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 drug test (G0482) rendered by the out-of-network (OON) provider on June 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections (CPT code(s): 64490 and 64491),
for the enrollee.
You asked the Plan to pre-approve the injections. You say that the enrollee needs this procedure. The Plan
denied your request. The Plan says the enrollee's request is not medically necessary because the enrollee's
records show they have acute type pain associated with radiculopathy.
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 injections. Our physician reviewer
found the enrollee has multiple other pain generators. The LCD criteria are not met because of the presence of
these other pain generators. The request is not medically necessary or reasonable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not
have to pre-approve facet joint injections (CPT code(s): 64490 and 64491), for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CT scan, thorax, diagnostic; without contrast material (CPT code 71250), for the enrollee.
You asked the Plan to pre-approve the CT scan. You say that the CT scan is necessary. The Plan denied your request. The Plan says the CT Thorax the enrollee received on September 24, 2021, was stable with no acute lung pathology. The Plan states there is no clinical documentation presented that supports a six-month follow-up.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 pre-approve the CT scan. Our physician reviewer found the record indicates that the enrollee has a cavitary lesion and was treated for infection. The record indicates that the enrollee had a CT chest in October 2021 that was stable from the previous one in March 2021. The provided records do not indicate the medical necessity or reasonableness, as defined by Medicare rules, of the requested service at this time. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve the CT scan, thorax, diagnostic; without contrast material (CPT code 71250), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on April 19, 2021, by an out-ofnetwork
(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 April 19, 2021, by an
out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says custodial care is not a covered benefit.
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 the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, you do not require the necessary services on an inpatient basis, in a skilled nursing facility setting. you have had therapy in the IRF and did not require a transfer to a SNF over a discharge to a home or community setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient hospital facility visit provided
on August 25, 2020.
You asked the Plan to waive the copayment for an outpatient hospital facility visit. You say that you disagree
with how high the charges are for the services you received. The Plan denied your request. The Plan says the
claims were processed correctly and you are being charged the correct 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 $350
copayment for outpatient hospital services.
You have been asked to pay the allowed amount of $118.51, which is less than the $350 copayment for an
outpatient hospital facility visit. An outpatient hospital facility visit falls within the outpatient hospital 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 an outpatient hospital facility
visit provided on August 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the tetanus, diphteria toxoids, and acellular pertussis (Tdap) vaccine provided on August 16, 2021.  You asked the Plan to pay for the Tdap vaccine. You say that you were advised to receive this vaccine by your provider. The Plan denied your request. The Plan says this vaccine is not among those covered under your medical benefit.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap vaccine. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to the Tdap vaccine. Therefore, we decided that the Plan does not have to pay for the tetanus, diphteria toxoids, and acellular pertussis (Tdap) vaccine provided on August 16, 2021.   Benefits for the Tdap vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous implantation of neurostimulator electrode array (63650).
You asked the Plan to pre-approve an implantation of neurostimulator electrode array. You say that the requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for the requested service have not been met.
The Plan must follow Medicare rules. The rules say that no payment may be made for the implantation of dorsal column or depth brain stimulators or services and supplies related to such implantation, unless all of the conditions listed in the Medicare rules section have been met.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an implantation of neurostimulator electrode array have not been met. Specifically, the provided medical records do not indicate that the enrollee's screening for the requested services included psychological evaluation. Therefore, we decided that the Plan does not have to pre-approve a percutaneous implantation of neurostimulator electrode array (63650).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Botox injections (J0585) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve Botox injections. You say that to force the enrollee to go in network versus out of network, care would be to force inequitable care on a condition affected by 12% of the population. The Plan denied your request. The Plan says the services can be provided in 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 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 Botox injections (J0585) to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Minuteman posterior arthrodesis of the L4-L5 for the enrollee.  You asked the Plan to pre-approve these services. You say that these services are 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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The Minuteman device is experimental. More research is needed to show safety and efficacy of the device. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Minuteman posterior arthrodesis of the L4-L5 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retreatment of a previous root canal (D3348) provided on
September 13, 2021.
You asked the Plan to pay for the dental service. You say that you just purchased the most expensive plan. You
also say that it should cover root canal work. The Plan denied your request. The Plan says retreatment of a
previous root canal is not a covered service.
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 retreatment of a previous root canal
is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
retreatment of a previous root canal (D3348) provided on September 13, 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 the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically
necessary.
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 documentation provided you do not require the intensity of services
provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services
and regular physician evaluation. Your care needs can be met at a lower level of 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus vaccine and administration provided on September 13, 2021.
You asked the Plan to pay for the vaccine services. You say that you believe that this should be covered by the Plan. The Plan denied your request. The Plan says this vaccine is not among those covered when performed as a preventative procedure.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine services. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the vaccine services. Therefore, we decided that the Plan does not have to pay for the tetanus vaccine and administration provided on September 13, 2021.
Benefits for the vaccine services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on October
26, 2021.
You asked the Plan to pay for the periodontal maintenance. You say that after your visit on April 21, 2021 you
scheduled a teeth cleaning with periodic evaluation, not a periodontal maintenance. You also say that on
October 26, you received a routine cleaning, a periodic evaluation, topical fluoride varnish, and a periapical
first film, but the clinic filed the claim wrong as a periodontal maintenance. The Plan denied your request. The
Plan says this service is limited to one per calendar year. The Plan also says that your dental records show that
you had a periodontal maintenance billed and paid for on the April 21, 2021, date of service.
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, periodontal maintenance (D4910) is
limited to one per 12 months. The record shows that you received a periodontal maintenance (D4910) on April
21, 2021, and your periodontal maintenance (D4910) benefit has been exhausted. Therefore, we decided that
the Plan does not have to pay for the periodontal maintenance (D4910) provided on October 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on May 27, 2021 by an
out-of-network (OON) provider.
You asked the Plan to pay for the OON drug testing. You say that this was medically necessary testing. The
Plan denied your request. The Plan says this was ordered by an OON provider from an OON laboratory. No
authorization was given for these services which could have been provided in-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 pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on May 27,
2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Mycophenolate mofetil for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan
denied your request. The Plan says that this is not covered by the Plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Mycophenolate mofetil for
the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis tablet 5mg.
You asked the Plan to pre-approve the drug. You say that there was a nosebleed with Xarelto, and the enrollee
tolerated Eliquis without any issues. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis tablet 5mg.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient echocardiography (93306) provided on May 26, 2021.
You asked the Plan to waive the copayment for the outpatient echocardiography. You say that the services should be covered as you had them performed previously on October 9th, 2020 and did not have a copayment. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.
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 $400 copayment for Outpatient diagnostic tests and therapeutic services and supplies.
You have been asked to pay a $400 copayment for an outpatient echocardiography. The Plan states that they reviewed your previous claim, and a $400 copayment was supposed to apply but didn't due to a claim processing error, they have decided not to retroactively apply the copayment. the outpatient echocardiography falls within the Outpatient diagnostic tests and therapeutic services and supplies 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 an outpatient echocardiography (93306)
provided on May 26, 2021.