Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the consultation (D9310).  You asked the Plan to pre-approve the consultation (D9310). You say that it would be necessary for the oral surgeon to examine your tooth and the additional effort would not be available with a regular dentist. You say that because there is additional danger, the procedure requires an oral surgeon and coverage for the consultation should be provided. The Plan denied your request. The Plan says the service is 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 pre-approve the consultation (D9310).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound (76700} provided on July 3, 2021 by an out-of-network (OON)  provider.  

You asked the Plan to pay for the ultrasound. You say that a provider was sent to the enrollee's home by an in network provider due to mobility issues. You also say that the service should be covered. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that prior authorization was not obtained. The Plan also says that the services 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 ultrasound (76700} provided on July 3, 2021 by an out-of-network (OON)  provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve facet joint nerve radiofrequency ablation (64635, 64636).  You asked the Plan to pre-approve facet joint nerve radiofrequency ablation. You say that this is medically necessary. The Plan denied your request. The Plan says the requirements for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that the thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet joint (medial branch) nerves are considered medically reasonable and necessary for patients who have had at least two (2) medically reasonable and necessary diagnostic medial branch blocks (MBBs), with each one providing a consistent minimum of 80% sustained relief of primary (index) pain (with the duration of relief being consistent with the agent used).  We looked at the file and Medicare rules. The submitted medical records show that the enrollee's second MBB provided only 70% pain relief. Based on this information, we decided that Medicare rules for coverage of facet joint nerve radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint nerve radiofrequency ablation (64635, 64636).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve deep sedation  You asked the Plan to pre-approve deep sedation. The Plan denied your request. The Plan says the service is 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 pre-approve deep sedation
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the catheter procedure provided on August 13, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the catheter procedure. 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 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. 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 catheter procedure provided on August 13, 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 medical services provided on February 4, 2021 to February 8, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the OON medical services. You say that these services were provided during the month it took to switch insurance companies due to lack of care during illness. The Plan denied your request. The Plan says the provider of these services is not participating with Medicare and there is no indication there was an emergency or urgent situation.  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 medical services provided on February 4, 2021 to February 8, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve SNF care.  You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a medical necessity for you. The Plan denied your request. The Plan says medical necessity rules for SNF care have not been met.  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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that you have no identifiable skilled nursing service needs. You do have identifiable skilled therapy service needs; however, 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 skilled nursing facility 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory work provided on July 28, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the laboratory work. You say that all the current procedural terminology (CPT) codes are Medicare-approved codes and should be covered. 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 services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the laboratory work provided on July 28, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Urolift procedure.  You asked the Plan to pre-approve the Urolift procedure. You say that the Urolift procedure is medically necessary. The Plan denied your request. The Plan says the Urolift procedure is 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 the Urolift procedure. Our reviewer says that the Urolift procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has a maximum urinary flow rate of 58.9 cc/s which does not indicate bladder outlet obstruction. A maximum flow rate of less than 12 cc/s is required to cover the Urolift procedure.   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 Urolift procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Urolift procedure.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the x-ray exam of the foot (73630) rendered by the out-of-network (OON) provider on August 3, 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 x-ray exam of the foot (73630) rendered by the out-of-network (OON) provider on August 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an office visit (99214) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve an office visit. You say that this care is medically necessary. The Plan denied your request. The Plan says there are in-network providers able to treat the enrollee's condition.  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 an office visit (99214) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a hospital bed (E0265) and supplies provided on April 5 to June 9, 2021, by an out-of-network provider.  You asked the Plan to pay for a hospital bed and supplies. You say that the items at issue were a necessity because you could not get equivalent items through the Plan. 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. There is no documentation that the Plan did not have network providers available to provide 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 hospital bed (E0265) and supplies provided on April 5 to June 9, 2021, by an out-of-network provider.
Appeal type: Testing
Decision: Favorable

 We decided that the Plan has to pre-approve bioimpedance spectroscopy using the ImpediMed L-Dex device.  You asked the Plan to pre-approve bioimpedance spectroscopy using the ImpediMed L-Dex device. You say that bioimpedance spectroscopy using the ImpediMed L-Dex device is medically necessary. The Plan denied your request. The Plan says that bioimpedance spectroscopy using the ImpediMed L-Dex device is not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 bioimpedance spectroscopy using the ImpediMed L-Dex device. Our reviewer says that bioimpedance spectroscopy using the ImpediMed L-Dex device id considered medically reasonable and necessary in this case. Our physician reviewer found that bioimpedance spectroscopy for breast cancer related lymphedema assessment has become a standard of care for prevention and treatment. Clinical measurements are obtained initially to establish a baseline before breast cancer treatments and afterward at intervals to track changes during treatment. Alternatively, changes in arm circumference or volume relative to the contralateral normal limb can be performed. Given that the highest risk of developing lymphedema is within the first three years of treatment and that early intervention can limit progression of disease, high-risk patients should be followed closely in this period. Assessing at baseline prior to surgery offers valuable clinical information. This enrollee has a planned mastectomy and likely axillary lymph node sampling. The service is reasonable and 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 bioimpedance spectroscopy using the ImpediMed L-Dex device have been met. Therefore, we decided that the Plan has to pre-approve bioimpedance spectroscopy using the  ImpediMed L-Dex device.   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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 5, 2020.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the records do not support the services billed.  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 find that the various denied codes are not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a nursing and rehabilitation center (POS 32). 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 August 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) and intraoral - complete series of radiographic images (D0210) provided July 26, 2021.  You asked the Plan to pay for the comprehensive oral exam and complete series of x-rays. You say that you were unaware of the frequency limit and the services were necessary upon finding a new, reputable provider. The Plan denied your request. The Plan says you have exceeded the frequency limit for these 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. The Plan covers the comprehensive oral exam and complete series of x-rays once every three plan years.  We looked at the file, and Medicare rules. The Plan provided documentation showing that a comprehensive exam and complete series of x-rays were previously covered on March 11, 2020. Based on this information, we decided that the Plan's frequency limit for coverage of the comprehensive oral exam and intraoral x-rays has been exceeded. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) and intraoral - complete series of radiographic images (D0210) provided July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a practitioner visit provided on July 3, 2021.  You asked the Plan to pay for practitioner visit. You say that the enrollee saw 2 providers on the same date due to being COVID-19 positive. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this evaluation and management (E&M) visit was not billed with the appropriate modifier to indicate that it was unrelated to the minor surgical procedure performed on this date of service.  The Plan must follow Medicare rules. Medicare rules say that evaluation and management services provided on the same day as a minor surgery are included in the payment for the procedure unless they are a significant, separately identifiable service and billed with the -24 modifier.   We looked at the file and Medicare rules. This code was not billed with the appropriate -24 modifier to indicate that it was separate from the minor surgical service performed on this date of service. Based on this information, we decided that Medicare rules for coverage of practitioner visit have not been met. Therefore, we decided that the Plan does not have to pay for a practitioner visit provided on July 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve portable oxygen concentrator, rental (CPT code E1392).  You asked the Plan to pre-approve the DME. You say that you have been carrying the canister around for a while now. The Plan denied your request. The Plan says they do not cover duplicate or redundant durable medical equipment such as oxygen device when the second item performs the same function as the one currently provided to the enrollee. The Plan states there is no medical documentation to support your need for a portable oxygen concentrator.  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 DME. Our physician reviewer found a portable concentrator is not medically necessary. The records do not include documentation of hypoxemia (O2 saturation less than 89%) during activity.  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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve portable oxygen concentrator, rental (CPT code E1392).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for outpatient hospital services provided from June 9, 2021, to June 30, 2021.  You asked the Plan to waive the copayment for outpatient hospital services. You say that you did not receive these services and feel that you are being confused with another enrollee. 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 $95 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers.   The medical records show that you received outpatient hospital services from June 9, 2021, to June 30, 2021, for a total of 3 services. Therefore, you are responsible to pay a $95 copayment per each service. The total amount you owe is: $285.   You have been asked to pay the total copayment amount of $285 for outpatient hospital services. Outpatient hospital services fall within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 outpatient hospital services provided from June 9, 2021, to June 30, 2021.