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

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).

You asked the Plan to pre-approve 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 RFA is covered when specific criteria are met. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has thoracic facet pain. She had diagnostic thoracic medial branch blocks (MBBs) that provided near total pain relief. She did not have a second set of confirmatory MBBs. The Medicare rules require two separate sets of diagnostic MBBs that provide greater than 80 percent pain relief before RFA may be performed. The RFA is 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 radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on March 18, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 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 out of network physician services provided to the enrollee on March 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture (D5110) provided on May
18, 2021.

You asked the Plan to pay for the complete maxillary denture. You say that you contacted the Plan and were
told the denture would be covered. The Plan denied your request. The Plan says this service is not a covered
benefit under your dental plan. The Plan also says that you contacted the Plan's customer service department
after the service was rendered.

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 the
complete maxillary denture (D5110) provided on May 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), preventive procedure (D1999), guided tissue regeneration (D4267), surgical extraction (D7210), and bone replacement graft for ridge preservation (D7953) provided on March 16, 2021 by an OON provider.

You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, preventive procedure, guided tissue regeneration, surgical extraction, and bone replacement graft. You say that you were unable to go to an in-network provider because you were refused service and you needed emergency treatment. The Plan denied your request. The Plan says the provider who performed these services is not in the Plan's network. The Plan also says that while you are a member of this Plan, you must use network providers to receive dental services.

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 covered when they are received OON. The record shows that the Plan contacted the in-network provider you were scheduled to see, and this office advised that you did not show up for your appointment. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), preventive procedure (D1999), guided tissue regeneration (D4267), surgical extraction (D7210), and bone replacement graft for ridge preservation (D7953) provided on March 16, 2021 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a left knee arthroscopy.

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 there is no documentation of a trial and failure of recent reasonable and comprehensive less-invasive conservative care measures. The enrollee received an injection on July 8, 2021 with no documentation of results. True mechanical symptoms are not demonstrated on exams provided for review. The requested procedure is not supported without failure of conservative measures without mechanical locking. There is no compelling rationale presented or extenuating circumstances noted to support that the surgery is 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 left knee arthroscopy.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure) (CPT code: 95885-26-59 X2), nerve conduction studies; 3-4 studies (CPT code 95908-26), short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head (CPT code 95927-26-59), neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method (CPT code 95937-26), and electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery) (CPT code 95955-26-XU) provided to the enrollee on January 14, 2021.

You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We asked our coder 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 services. Our reviewer found the review indicates that the services were not documented in the medical record. Not all services were documented as reported by the code. Summaries were provided but the technical aspects as demonstrated by the specific codes was not documented in the medical record. The review has determined that the services as billed are not supported by the records. 

We looked at this coder'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 pay for the services (CPT code(s): 95885-26-59 X2, 95908-26, 95927-26-59, 95937-26, and 95955-26-XU) provided to the enrollee on January 14, 2021.
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 you are still recovering from surgery. The Plan denied your request. The Plan says you do not require daily skilled services on an inpatient basis.
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 physician reviewer found that from a nursing perspective, you received oral medications and had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, you were at a standby assist to contact guard assist level with functional mobility. You required varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 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: 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. The Plan denied your request. The Plan says your care is routine in nature.

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 physician reviewer found that you are at a contact guard assist level for sitting up, moderate assist for standing, and contact guard assist for transfers and sitting down. 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.

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 pre-approve the facet joint injection (CPT code 64495).

You asked the Plan to pre-approve the injection. You say that it is medically necessary to have this treatment as you are in lot of pain and other treatment is not effective to relieve the symptoms. The Plan denied your request. The Plan says your request is not medically necessary because your records show that you have problems at two (2) lumbar spinal regions, and the necessity of a third level is not documented.

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 injection. Our physician reviewer found that you have radiculopathy. According to the coverage criteria, facet injections are only indicated in the absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst). The review has determined that the medical records provided do not meet the requirements listed in the LCD for Medicare 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve the facet joint injection (CPT code 64495).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on
March 3, 2021.

You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request.
The Plan says your Plan covers ambulance transportation only when you are actually transported by
ambulance. Since you were not transported by this ambulance, the service is not covered by your plan.

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 March 3, 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
provided on March 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431), gingival
irrigations (D4921), drugs or medicaments dispensed in the office for home use (D9630), crown (D2740),
retainer crowns (D6740), and extraction (D7140) provided on April 8, 2021, and April 23, 2021.

You asked the Plan to pay for the adjunctive pre-diagnostic test, gingival irrigations, drugs or medicaments,
crown, retainer crowns, and extraction. The Plan denied your request. The Plan says the adjunctive prediagnostic
test, gingival irrigation, and drugs or medicaments are not covered benefits under your dental plan.
The Plan also says that your annual dental allowance has been exhausted.

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 adjunctive pre-diagnostic test
(D0431), gingival irrigation (D4921), and drugs or medicaments dispensed in the office for home use (D9630)
are not among those covered under this benefit. The Plan offers a $1,000 annual dental benefit maximum. The
contract says that after your annual maximum benefit maximum has been met, you are responsible for the full
charges of any additional dental services. The record shows that you met the annual maximum benefit on April
23, 2021 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not
have to pay for the adjunctive pre-diagnostic test (D0431), gingival irrigations (D4921), drugs or medicaments
dispensed in the office for home use (D9630), crown (D2740), retainer crowns (D6740), and extraction
(D7140) provided on April 8, 2021, and April 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on April 6, 2021 by an OON provider.

You asked the Plan to pay more for the periodic oral evaluation and prophylaxis. You say that the Plan contract does not state that the $500 dental benefit is paid based on an agreed to terms and conditions payment. You also say that you feel the booklet is misleading. The Plan denied your request. The Plan says the OON member liability was applied correctly per your plan benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for the difference between the billed amount and allowed amount for dental services received OON. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on April 6, 2021 by an OON provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a colonoscopy, specialist services, and
does not have to waive the coinsurance for Medicare Part B drugs provided on May 20, 2021.

You asked the Plan to waive the copayments for a colonoscopy, specialist services, and to waive the
coinsurance for Medicare Part B drugs. You say that you should not owe a copayment for a colonoscopy
screening. 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 $150
copayment for outpatient surgery, including services provided at hospital outpatient facilities. Your contract
with the Plan also clearly says that you must pay a $30 copayment for specialist services. Your contract with
the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs.

The medical records show that you had polyps removed during a colonoscopy on May 20, 2021. Therefore, the
colonoscopy is considered diagnostic, not preventative, and you are responsible to pay the $150 copayment.

You received specialist services on May 20, 2021. Therefore, you are responsible to pay the $30 copayment.

You received Medicare Part B drugs on May 20, 2021. The total allowed amount is $78.22 and 20% of that is
$11.74.

The total amount you owe is: $191.74.

You have been asked to pay the total amount of $191.74 for a colonoscopy, specialist services, and Medicare
Part B drugs. A colonoscopy falls within the outpatient surgery, including services provided at hospital
outpatient facilities and ambulatory surgical centers benefit category. Specialist services fall within the
physician/practitioner services, including doctor's office visits benefit category. Medicare Part B drugs fall
within the Medicare Part B prescription drugs 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 copayments
for a colonoscopy, specialist services, and does not have to waive the coinsurance for Medicare Part B drugs
provided on May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genicular nerve block.
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 the enrollee has bilateral knee osteoarthritis. The requested genicular nerve block is considered experimental/investigational in nature and is the subject of ongoing clinical trials. 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 genicular nerve block.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a LINX procedure.

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 the records show that you have episodic
gastroesophageal reflux (GERD), but there is no evidence of advanced esophagitis by upper endoscopy criteria.
There are no formal testing results for difficulty swallowing (dysphagia). There is limited documentation to
support that the symptoms are related to acid reflux. The records do not support that the LINX procedure is
reasonable or medically necessary at this time.

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 LINX procedure.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 15, 2020.
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on September 14, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services provided on September 15, 2020