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

We decided that the Plan does not have to pre-approve facet joint injections for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says a history of numbness and weakness is not consistent with axial pain.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is evidence of radiculopathy.
The pain is associated with radiculopathy and there is no documentation indicating that the facet joint is the main source of pain. 

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 facet joint injections for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 18, 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 this testing is unlikely to impact therapeutic decision making in the clinical management of this enrollee.

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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found genetic testing procedures submitted with code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the enrollee. The enrollee does not meet the criteria for this request. 

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 pay for laboratory services provided to the enrollee on March 18, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on January 28, 2021.

You asked the Plan to waive the copayment for the ultrasound. You say that you were not expecting to pay a copayment with this plan. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $50 copayment for Medicare-covered diagnostic radiology services received in a provider's office or freestanding facility.

You have been asked to pay $50 copayment for the ultrasound. The ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you received an ultrasound which is considered a diagnostic radiological service. 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 ultrasound provided by Elite Imagine, LLC, on January 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Myrbetriq tablets.
You asked the Plan to pre-approve Myrbetriq tablets. You say that the enrollee has tried other medication without success. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.
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 Myrbetriq tablets.
Benefits for Myrbetriq tablets 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the left knee.

You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says the medical office notes did not report any tests done for the left knee, such as an x-ray.

The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. In addition, x-rays were not noted and/or provided (that are non-diagnostic.) There are no mechanical issues noted on exam. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for left knee MRI (magnetic resonance imaging) is 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 the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of the left knee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on
February 16, 2021.
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says services rendered by non-participating providers require prior authorization as outlined in the enrollee's Evidence of Coverage.
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 services 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 a domiciliary or rest home visit provided on February 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care provided from February 21, 2021, through March 4, 2021.
You asked the Plan to pay for subsequent hospital care. The Plan denied your request. The Plan says incomplete or incorrect documentation was received for review and medical records are still needed.
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.
We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical documents to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of subsequent hospital care have not been met. Therefore, we decided that the Plan does not have to pay for subsequent hospital care provided from February 21, 2021, through March 4, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the extremity study (93970) rendered by the out-of-network (OON) provider on November 13, 2020.
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 extremity study (93970) rendered by the out-of-network (OON) provider on November 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration for the enrollee.
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 use of bone marrow aspirate during spine surgery is not covered.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspiration remains experimental for use as bone graft substitute, More research is needed. 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 bone marrow aspiration for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specially tinted eyewear.
You asked the Plan to pre-approve specially tinted eyewear. You say that you need tints for your glasses due to a blind spot on your left eye. Without the tinting of the glasses, you experience blurred vision, and you cannot see properly. The Plan denied your request. The Plan says this service is not covered by the Plan.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says that you have a $400 vision allowance every year for the purchase of routine eyewear including the lenses and one pair of eyeglass frames or contact lenses. The Plan contract also says that eyewear does not include lens options, such as tints, progressives, transition lenses, polish and insurance. We looked at the file and the Plan's rules. The services at issue are not covered benefits of Medicare or the Plan Based on this information, we decided that the Plan's rules for coverage of specially tinted eyewear. have not been met. Therefore, we decided that the Plan does not have to pre-approve specially tinted eyewear.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the 20% coinsurance charged for diabetic footwear purchased on April 1, 2021.

You asked the Plan to waive this coinsurance. You say that the provider told you these were covered in full. You say that you cannot afford this bill. The Plan denied your request. The Plan says this cost share is clearly outlined in your Plan contract and was charged based on the claim submitted by your provider.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The contract with the Plan clearly says that enrollees must pay 20% coinsurance for diabetic footwear. You have been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation. Therefore, we decided that the Plan does not have to waive the 20% coinsurance charged for diabetic footwear purchased on April 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the tissue exam provided on May 4, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the tissue exam. You say that the service was referred by an authorized provider for an authorized procedure. 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 record shows there was no referring provider. Therefore, we decided that the Plan does not have to pay for the tissue exam provided on May 4, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on May 2, 2021 and billed under claim A with code 99212.

You asked the Plan to pay for services billed under claim A. You say that this claim should be paid. The Plan denied your request.

The Plan says claim A denied because it was billed with CPT 99212 and a payment was previously made for this service under claim B by another provider with code 01740. The Plan states both providers have the same primary specialty and practice within the same group.

The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one service may be reported unless the services are for unrelated problems. Based on the documentation provided, this claim cannot be paid as billed due to the physician group relationship between the two providers and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on May 2, 2021 and billed under claim A.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on April 26, 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 office visit (99214) rendered by the out-of-network (OON) provider on April 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied your request. The Plan says the requested procedure is not considered medically necessary at this time and cannot be approved.
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 injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, the record indicates that the enrollee had a first injection that provided 30% pain relief. 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 the injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - periapical each additional radiographic image
(D0230) provided April 15, 2021.

You asked the Plan to pay for the additional intraoral x-rays. You say that you shouldn't have to pay anything.
The Plan denied your request. The Plan says you have exceeded frequency limits for this 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. The Plan covers the additional
intraoral x-rays once per calendar year.

We looked at the file and Medicare rules. The Plan provided documentation showing that an intraoral x-ray
was covered on the same date of service. Based on this information, we decided that the Plan's frequency limit
for coverage of intraoral x-rays has been exceeded. Therefore, we decided that the Plan does not have to pay
for the intraoral - periapical each additional radiographic image (D0230) provided April 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) and the intraoral complete series of x-rays (D0210) provided on March 29, 2021.

You asked the Plan to pay for the dental services. You say that the enrollee went for a dental cleaning and received non-covered services without being informed. The Plan denied your request. The Plan says the enrollee had a comprehensive oral evaluation in May of 2020 which was covered by the Plan. Only one comprehensive or periodontal exam may be covered every three years. In addition, a complete series of intraoral x-rays is not covered by the Plan's dental 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 or are requested in a frequency that exceeds the Plan's limitations. Documentation shows that the enrollee received a comprehensive oral evaluation less than three years prior to the date in question. A complete series of full mouth intraoral x-rays are not listed as a covered service. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) and the intraoral complete series of x-rays (D0210) provided on March 29, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the abdominal ultrasound provided on January 28, 2021.
You asked the Plan to waive the copayment for the abdominal ultrasound. You say that you were not expecting to pay a copayment with this plan. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $50 copayment for Medicare-covered diagnostic radiology services received in a provider's office or freestanding facility.
You have been asked to pay $50 copayment for the abdominal ultrasound. The abdominal ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you received an abdominal ultrasound which is a diagnostic radiological service. 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 abdominal ultrasound provided on January 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve kyphoplasty for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show a new fracture in the past 12 weeks.
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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee sustained an L1 compression fracture in February 2021. The enrollee has passed the subacute phase, which is where evidence-based therapy supports kyphoplasty. Therefore, the request is not deemed medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve kyphoplasty for the enrollee.
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 o
April 12, 2021.

You asked the Plan to pay for these services. You say that these services should be paid by the Plan. 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 o April 12, 2021.