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

 We decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency transport (A0427), and ground mileage (A0425) provided on August 1, 2020.  

You asked the Plan to pay for the transportation services. You say that you are unsure if you are responsible for the services or not. The Plan denied your request. The Plan says the claim for the services in this case was received outside of the 12 month timeframe.  

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.  

The record shows that a claim for the transportation services was not filed until October 13, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency transport (A0427), and ground mileage (A0425) provided on August 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Emgality.  

You asked the Plan to pre-approve Emgality. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.  

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 Emgality.   

Benefits for Emgality 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: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Injectafer.  You asked the Plan to pre-approve Injectafer. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 Injectafer. Our reviewer says that the medication is not medically necessary. Our physician reviewer found in this case, the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have to pre-approve Injectafer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four two-dimensional (2D) oral/facial photographic images (D0350 x4), cone beam computed tomography (CT) capture and interpretation (D0367), and five additional intraoral periapical x-rays (D0230 x5) provided on September 9, 2021.

You asked the Plan to pay for the 2D oral/facial photographic images, cone beam CT capture and interpretation, and additional intraoral periapical x-rays. You say that you went to the dentist to inquire about a tooth extraction, and they took x-rays that were not covered under your plan. The Plan denied your request. The Plan says 2D oral/facial photographic image and cone beam CT capture and interpretation are not covered expenses under your dental plan. The Plan also says that your benefits for intraoral x-rays have been satisfied and the frequency limitation had been exceeded.

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, 2D oral/facial photographic image (D0350) and cone beam CT capture and interpretation (D0367) are not among those covered under this benefit. The contract says that intraoral x-rays are limited to one procedure code per calendar year. The record shows that you received a first intraoral periapical x-ray (D0220) on September 9, 2021 which was covered by the Plan and your intraoral x-rays benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the four two-dimensional (2D) oral/facial photographic images (D0350 x4), cone beam computed tomography (CT) capture and interpretation (D0367), and five additional intraoral periapical x-rays (D0230 x5) provided on September 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) by a participating provider on September 13, 2021.
You asked the Plan to pay for a comprehensive oral evaluation. You say that you were told that there would no charges applied to your visit. The Plan denied your request. The Plan says the benefit limit for a comprehensive oral evaluation had already 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. The Plan covers one comprehensive oral evaluation every three calendar years.
We looked at the file and Medicare rules. Evidence was provided to show that a comprehensive oral evaluation on January 8, 2020. Based on this information, we decided that the Plan's rules for coverage of a
comprehensive oral evaluation have already been exhausted. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a participating provider on September 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on August 30, 2021.

You asked the Plan to pay for the dental service. You say that you were in the hospital for 3 months after 
surgery. You say that with all of the medication you were on has resulted in your teeth suffering. You also say 
that you were not aware of the frequency limit. The Plan denied your request. The Plan says prophylaxis is 
covered twice per plan year. The Plan also says that the frequency limit has been exceeded.

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 and prophylaxis is listed as a covered 
service, the frequency limit has been exceeded. The record shows that the Plan paid for prophylaxis that you 
received on January 14, 2021, and April 12, 2021. Therefore, we decided that the Plan does not have to pay for
the prophylaxis (D1110) provided on August 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction (92015) provided on September 15, 2021.
You asked the Plan to pay for the eye refraction. You say that this is an in-network provider and this service should be covered. The Plan denied your request. The Plan says this service was provided as part of a medical eye exam for a diagnosis of Type 2 Diabetes Mellitus without complications. Eye refractions are only covered by your plan if performed by a provider in the routine vision vendor network as part of a routine (non-medical) vision screening. Therefore, the eye refraction is denied.
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 covers these services when they are performed as part of a routine (non-medical) eye exam performed by a provider in the Plan's specified routine vision vendor network. We looked at the file and the Plan's rules. Documentation shows that this service was performed as part of a medical eye exam. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on September 15, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 based on the medical records provided you do not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part time basis appear appropriate in this case.

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 skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve implantation of a cranial nerve neurostimulator electrode array and pulse generator.  You asked the Plan to pre-approve implantation of a cranial nerve neurostimulator electrode array and pulse generator. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan follows Medicare rules. Medicare rules say that VNS 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 implantation of a cranial nerve neurostimulator electrode array and pulse generator. Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case, all of the requirements for coverage have not been satisfied 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 implantation of a cranial nerve neurostimulator electrode array and pulse generator have not been met. Therefore, we decided that the Plan does not have to pre-approve implantation of a cranial nerve neurostimulator electrode array and pulse generator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve OsteoCel allograft.

You asked the Plan to pre-approve OsteoCel allograft. 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 OsteoCel allograft. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Osteocel allograft remains experimental for use in spinal surgery as bone graft. Iliac crest is the gold standard. 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 OsteoCel allograft have not been met. Therefore, we decided that the Plan does not have to pre-approve OsteoCel allograft.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiologic examination, chest (71045) provided January 
28, 2021.

You asked the Plan to pay for the radiologic service. You say that the enrollee had multiple exams on this date 
of service. Attached reports to support level of service. Please reconsider for processing. The Plan denied your 
request. The Plan says this claim was already processed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code 71045 is radiologic examination, chest. 

We find that CPT code 71045-26 is not supported in the medical record. Specifically, the submitted 
documentation supports that only one unit of 71045-26, which has already been approved and paid by the Plan 
on check dated March 22, 2021. Based on this information, we decided that Medicare rules for coverage of the 
radiologic service have not been met. Therefore, we decided that the Plan does not have to pay for the 
radiologic examination, chest (71045) provided January 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Signatera testing rendered on April 19, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the Signatera testing rendered on April 19, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services billed with Patient-Driven Payment Model (PDPM) GAPD1.

You asked the Plan to pay for the SNF services billed with PDPM GAPD1. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed require a corrected claim.

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 SNF services with PDPM GAPD1 is not supported in the medical record. Specifically, the documentation shows that the claim was billed with a PDPM that was different that the approved PDPM code. This means the PDPM code is not payable as billed and this claim requires a corrected claim to be submitted for review. Based on this information, we decided that Medicare rules for coverage of the SNF services billed with PDPM GAPD1 have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services billed with Patient-Driven Payment Model (PDPM) GAPD1.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to hold you harmless for the colorectal cancer screening for a high-risk individual (G0105) provided on May 28, 2021.

You asked the Plan to hold you harmless for the screening. You say that the provider is billing you the full cost of this service and want to know when this claim will be paid. The Plan denied your request. The Plan says that they need an explanation of benefits from your other insurance before this claim can be considered.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. However, Plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. Medicare rules also say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. 

The Plan has not met its obligation with regards to coordination of benefits. Specifically, the Plan has not identified the primary payer in this case. The Plan has not directed the provider to bill this payer. The Plan has not forwarded the bill to the primary payer or paid the bill and submitted a request for reimbursement to the primary payer.

You were referred for the screening by a contract provider. The file does not show that the Plan provided notice that the screening would not be covered. Under Medicare rules, this means the screening is considered approved by the Plan. While the Plan may or may not be responsible for some or all of the cost of this service after coordinating your benefits with the primary payer, this issue of coordination is not your responsibility and you should not be receiving a bill for these services. Therefore, we decided that the Plan has to hold you harmless for the colorectal cancer screening for a high-risk individual (G0105) provided on May 28, 2021.

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 the laboratory services (81001, 87086, 87088, 87186) rendered by the out-of-network (OON) provider on September 7, 2021.

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 laboratory services (81001, 87086, 87088, 87186) rendered by the out-of-network (OON) provider on September 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found IRF admission is not medically necessary based on lack of medical complexity and nursing needs and high functional level. Documentation does not support the necessity for admission to IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99215) provided on August 18, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that please see attached chart for proof of services. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 has network providers available who can 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 the outpatient office visit (99215) provided on August 18, 2020 by an out of network (OON) provider.