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

We decided that the Plan does not have to pre-approve four (4) office visits with a specialist (92004, 92002, 99204, 99205) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve office visits with a specialist. You say that the enrollee needs to see a cornea specialist for corneal surgery. The Plan denied your request. The Plan says services should be received from network providers who are listed in the provider directory, except when urgent or an emergency.
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. The records provided for review do not show that the services at issue are urgent or emergent. 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 four (4) office visits with a specialist (92004, 92002, 99204, 99205) to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SNF admission.
You asked the Plan to pre-approve SNF care. You say that you are unstable on your feet and you would benefit from SNF services. The Plan denied your request. The Plan says your needs are non-skilled in nature.
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 the member is medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The member does not have any parental medication; complex wound care or nutrition given via a feeding tube. She is medically stable without any acute exacerbations of chronic medical problems. Her physical function is at or near her baseline and she can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services is not 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve a SNF admission.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fusion surgery of the sacroiliac joint in the lower back. 
 
You asked the Plan to pre-approve fusion surgery of the sacroiliac joint in the lower back. You say that the 
medical records provided support the need for the requested outpatient surgery. The Plan denied your request. 
The Plan says the requested procedure is not considered 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 fusion surgery of the sacroiliac joint in 
the lower back. Our reviewer says that fusion surgery of the sacroiliac joint in the lower back is not considered 
medically reasonable and necessary in this case. Our physician reviewer found the sacroiliac joint does not 
show abnormality on imaging. The magnetic resonance imaging (MRI) shows lumbar spinal stenosis. The 
criteria for a sacroiliac joint fusion have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of fusion surgery of the sacroiliac joint in the lower back have not been met. Therefore, we decided that the Plan does not have to pre-approve fusion surgery of the sacroiliac joint in the 
lower back.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from March 11, 
2021, through March 17, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were in the hospital 
for coronavirus related health matter and you want the Plan to pay for the charges. The Plan denied your 
request. The Plan says the copayment was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment per day for days 1-7 for inpatient hospital care.  

You have been asked to pay a $1350 copayment for inpatient hospital care. The services at issue fall within the 
inpatient hospital care 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 inpatient 
hospital care from March 11, 2021, through March 17, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy (Upper
endoscopy) you had on May 13, 2021, at an ambulatory surgical center.
You asked the Plan to waive the copayment for the upper endoscopy. You say that if you had known there
would be a copayment, you would not have had the service. The Plan denied your request. The Plan says you
were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295
copayment for services at an ambulatory surgical center. You have been asked to pay a $295 copayment for the upper endoscopy. The upper endoscopy falls within the
services at an ambulatory surgical center 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 the esophagogastroduodenoscopy (Upper endoscopy) you had on May 13, 2021, at an ambulatory surgical
center.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Foundation Pain Index (FPI) testing (CPT code 0117U)
provided to the enrollee on May 13, 2021.
You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request.
The Plan says the clinical value and effectiveness of Foundation Pain Index (FPI) in the setting of concerns for
tolerance to pain medications has not been demonstrated in the peer-reviewed literature.
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 testing. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the clinical value and effectiveness of Foundation Pain Index (FPI) in the setting
of concerns for tolerance to pain medications has not been demonstrated in the peer-reviewed literature. The
review has determined that the items/services at issue in this case are 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 testing have not been met. Therefore, we decided that the Plan does not have
to pay for Foundation Pain Index (FPI) testing (CPT code 0117U) provided to the enrollee on May 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-ray (D0220) provided on May 12, 2021.
You asked the Plan to pay for the intraoral x-ray (D0220). You say that you were told you could get x-rays of
your teeth once a year. You say that you weren't informed only certain x-rays are covered and you should not
have to pay. 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 pay for the
intraoral x-ray (D0220) provided on May 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the destruction of lesion (except excision), dentoalveolar structures (41850) provided May 27, 2021.

You asked the Plan to pay for the destruction of lesion (except excision), dentoalveolar structures. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says the surgery provided was cosmetic in nature.

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 destruction of lesion (except excision), dentoalveolar structures. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Medicare does not provide dental benefits.

The plan's Administrative Guideline states that items and services in connection with the care and treatment of structures supporting the teeth are not covered. In this case, the record indicates that the enrollee underwent gingival plasty and implant debridement of a granuloma of a tooth supporting structure. The requested service is excluded by the plan's supplemental policy. 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 destruction of lesion (except excision), dentoalveolar structures have not been met. Therefore, we decided that the Plan does not have to pay for the destruction of lesion (except excision), dentoalveolar structures (41850) provided May 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve F2 and F5 genetic testing services.
You asked the Plan to pre-approve F2 and F5 genetic testing services. You say that the enrollee has repeated blood clots in his legs. The Plan denied your request. The Plan says the requested genetic testing is not covered by Medicare or under the enrollee's contract.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that genetic testing for the F2 and F5 genes are not considered medically necessary. Therefore, we decided that the Plan does not have to pre-approve F2 and F5 genetic testing services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient bronchoscopy procedure.
You asked the Plan to pre-approve inpatient bronchoscopy procedure. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 inpatient bronchoscopy procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found placement of endobronchial valves (EBV) is considered not medically necessary for this enrollee, because patient selection criteria are not met. EBV has been shown in multiple clinical trials to be a reasonably safe and effective treatment for selected patients with emphysema and air trapping. It is no longer considered experimental. However, patient selection criteria, based on the characteristics of patients included in the clinical trials, include residual volume (RV) at least 175% predicted. This enrollee's RV was 156% predicted. This enrollee's severity of air trapping is less than that of the patients participating in the clinical studies, indicating she may not benefit as much as the patients in the clinical studies.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient bronchoscopy procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient bronchoscopy procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99215) and the smoking and tobacco use
cessation counseling visit (99406) rendered by the OON provider on April 4, 2019.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. 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 the office visit (99215) and the smoking and tobacco use cessation counseling
visit (99406) rendered by the OON provider on April 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on May 17, 2021.
You asked the Plan to waive the copayment for these services. You say that you would like the copayment waived. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for per in-network specialist visit.
Review of the file shows that you received specialist services on May 17, 2021. You have been asked to pay a $40 copayment these services. These services fall within the in-network specialist visit 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 the specialist services rendered on May 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).

You asked the Plan to pre-approve the RFA services. You say that you are having issues walking and need therapy. The Plan denied your request. The Plan says the requested procedure is considered experimental and investigational.

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 RFA services. Our reviewer says that RFA services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was diagnosed with sacroiliitis. The enrollee received Epidural Steroid Injection (ESI) services at the right S1 level, which did not improve the right leg pain. Sacral lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and investigational. Radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, not 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 the RFA services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care billed with as secondary diagnosis code of acute respiratory failure with hypoxia (J96.01) provided March 3, 2020, to March 7, 2020.
You asked the Plan to pay for inpatient hospital care billed with as secondary diagnosis code of acute respiratory failure with hypoxia. You say that you would like this claim reprocessed as billed based on the medical records provided. The Plan denied your request. The Plan says the record does not support the secondary diagnosis code that was billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with J96.01 - Acute respiratory failure with hypoxia. 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 inpatient hospital care billed with as secondary diagnosis code of acute respiratory failure with hypoxia. Our reviewer says that the medical record does not support the diagnosis code as billed our physician reviewer found that review indicates that the enrollee was a then 78 year old female who was sent from her primary care physician office with dyspnea and hypoxemia on March 3, 2020. Pulse oximetry in the Emergency Department was 83% on room air. The enrollee was placed on 4- 6 liters high flow oxygen and saturation increased to 94%. Chest x-ray showed bibasilar opacities and the member was started on intravenous antibiotics, steroids and nebulizers. On March 4, 2020 the member's oxygen was decreased to 4 liters and was on nasal cannula. During the remaining 3 days of the hospitalization, the member continued on antibiotics, steroids and nebulizers. The member was then weaned off oxygen to room air on March 7, 2020 and discharged. The records did not document any arterial blood gas measurements--only oxygen saturations. There was no documentation of CO2 retention. Initial oxygen treatment was 6L/min, 4L/minute on day 2, with weaning to room air by March 7, 2020 (saturation 92%). The review has determined that the clinical documentation does support that the following diagnosis impacted this hospital admission-- J96.01 Acute Respiratory Failure With Hypoxia. The clinical notes support community acquired pneumonia and COPD exacerbation. There was no evidence for respiratory failure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital care billed with as secondary diagnosis code of acute respiratory failure with hypoxia (J96.01) provided March 3, 2020, to March 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the extractions provided on April 27, 2021.
You asked the Plan to pay more for the extractions. You say that you were not told only half of the extractions
would be paid for. You say that you should have been given all the information and the denial should be
reconsidered. The Plan denied your request. The Plan says the claim processed correctly.
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 also have a maximum benefit of
two extractions per calendar year. The Plan paid 50% of the cost for two extractions provided on April 27,
2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay more for the
extractions provided on April 27, 2021.