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

 We decided that the Plan does not have to pay for the periodic comprehensive preventive medicine reevaluation and management (CPT code 99397) provided on September 20, 2021.  You asked the Plan to pay for the service. You say that this was not a comprehensive physical exam, but a yearly female exam by your gynecologist. The Plan denied your request. The Plan says this service is limited to once a benefit year and the benefit limit has been reached.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. The health plan contract says that the routine physical examination is a comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, hands on examination, anticipatory guidance/risk factor reduction interventions. You exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the periodic comprehensive preventive medicine reevaluation and management (CPT code 99397) provided on September 20, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on September 9, 2021.  You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. You say that the ambulance transport was medically necessary. The Plan denied your request. The Plan says the ambulance transport was not medically necessary.  Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.   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 ambulance service, basic life support, non-emergency transport. Our reviewer says that the ambulance transport was not medically necessary. Our physician reviewer found that the record indicates that the enrollee has Alzheimer's disease and was transported from an acute care hospital to a skilled nursing facility.  The record indicates that the enrollee was ambulatory and siting in a chair upon emergency medical services (EMS) arrival. The record does not indicate that other means of transportation were contraindicated.  The elements of the coverage criteria are not satisfied. The requested service is not recommended.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance service, basic life support, non-emergency transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on September 9, 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 you need rehab to get your strength back. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.  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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that you require at least 3 hours a day for 5 days a week, or 15 hours over 7 consecutive days, of therapy services. No other indicators are identified that you require a rehabilitation therapy program sufficient for this level of care. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.  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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation (D0364) and problem focused limited oral evaluation (D0140) provided on June 28, 2021.  You asked the Plan to pay for the cone beam CT capture and interpretation and problem focused limited oral evaluation. You say that the exams were necessary to diagnose your need for a root canal because you saw two dentists. You also say that you could not go to a specialist without first being examined by your own dentist. The Plan denied your request. The Plan says the cone beam CT capture and interpretation is not a covered benefit under your dental plan. The Plan also says that the problem focused limited oral evaluation exceeds the frequency limitation in your benefit plan.  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. The contract says that problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on June 3, 2021 and your problem focused limited oral evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation (D0364) and problem focused limited oral evaluation (D0140) provided on June 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the fillings (D2392) for teeth # 29 and 30 provided on October 28, 2021.  You asked the Plan to pay for the dental services. You say that you received the annual notice of changes (ANOC) for 2022 in the mail. You say that you did not realize that the coverage outlined in the ANOC was not effective until January 1, 2022. The Plan denied your request. The Plan says the fillings are not listed as covered services.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the fillings are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the fillings (D2392) for teeth # 29 and 30 provided on October 28, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that you feel unsafe going home. The Plan denied your request. The Plan says that you no longer require skilled services and the continuation of SNF care is not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a raised toilet seat provided on July 29, 2021.  You asked the Plan to pay for a raised toilet seat. The Plan denied your request. The Plan says this item is not a covered benefit.  The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature.   While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a raised toilet seat provided on July 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Dulera.  You asked the Plan to pre-approve Dulera. The Plan denied your request. The Plan says Dulera is a self-administered drug. The Plan also says that Dulera does not fall under Part B 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 Dulera.   Benefits for Dulera 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the present setting where you are currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan.    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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to adjust the copayment for the office visit (99212) provided on September 8, 2021.  You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.  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 $35 copayment for Medicare-covered podiatry services. Covered podiatry services include diagnosis and the medical or surgical treatment of injuries and diseases of the feet. Additionally, routine foot care for members with certain medical conditions affecting the lower limbs are covered.    You have been asked to pay a $35 copayment for the Medicare-covered podiatry visit provided. 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 adjust the copayment for the office visit (99212) provided on September 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (CPT code 80307 and G0483) provided to the enrollee on March 2, 2021.  

You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.  

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. CPT code(s): 80307 and G0483, remain not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on March 2, 2021, and received by the lab on March 3, 2021; therefore, the billed code cannot be verified. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code 80307 and G0483) provided to the enrollee on March 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit (99213) provided on May 20, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the member does not have out-of-network benefits and the servicing provider is not a provider with the Plan.  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 an office visit (99213) provided on May 20, 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 the office visit provided on July 1, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an office visit the office visit. 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 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 office visit provided on July 1, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82310, 87728, 83540, 83350, and 84100) provided to the enrollee on May 3, 2021.  You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation submitted by the laboratory failed to show that the laboratory tests reported were unrelated to treatment of ESRD.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  Review of the file shows there is no modifier to indicate this would be separate from ESRD. The medical records also indicate that these lab services were related to ESRD. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82310, 87728, 83540, 83350, and 84100) provided to the enrollee on May 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure) (CPT code 64494 x 2) provided to the enrollee on April 13, 2021.  You asked the Plan to pay for the injections. You say that you submitted supporting documentation for reconsideration of denied codes. The Plan denied your request. The Plan says Medicare guidance says, HCPCS/ CPT Code: 64494 Practitioner Services MUE Values: 1 MUE Adjudication Indicator: 2 Date of Service Edit.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. As the HCPCS code 64494 exceed the allowable UOS of 1 for the same date of service per the MAI indicator of "2" and was not billed correctly per the bilateral surgery indicator of "1" guidance; we find that Medicare rule for payment of this claim has not been met. If the provider determines that a billing error occurred during the initial submission of the denied claim, the plan would accept a submission of a corrected claim to consider services for payment Therefore, we decided that the Plan does not have to pay for injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure) (CPT code 64494 x 2) provided to the enrollee on April 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the podiatry services received on September 29, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the podiatry services. You say that you disagree with the plan's decision. 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. Therefore, we decided that the Plan does not have to pay for the podiatry services received on September 29, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Neupogen (J1442).  You asked the Plan to pre-approve Neupogen. You say that the enrollee has used the generic bio similar in the past. The Plan denied your request. The Plan says the enrollee has not tried and failed the required drug.  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 Neupogen. Our reviewer says that the requested drug Neupogen is not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee has tried and failed the required drug, Zarxio (Filgrastim-sndz). The reviewer also found that the documentation does not support that Zarxio (Filgrastim-sndz) would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Therefore, the reviewer found that the requested drug is not medically necessary as the step therapy criteria 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 Neupogen have not been met. Specifically, the file does not indicate that the enrollee has tried and failed the required drug. Therefore, we decided that the Plan does not have to pre-approve Neupogen (J1442).