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

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) or pay more for the simple extraction (D7140) provided on August 18, 2021, and August 19, 2021

You asked the Plan to pay for the problem focused limited oral evaluation and to pay more for the simple extraction. You say that you were desperate to get your tooth removed due to pain and infection and you made an appointment with the oral surgeon that could treat you fastest. The Plan denied your request. The Plan says the problem focused limited oral evaluation exceeds the frequency limitation in your benefit plan. The Plan also says that the member liability was applied correctly per your Plan benefits.

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, problem focused limited oral evaluation (D0140) and is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on June 17, 2021 and your problem focused limited oral evaluation (D0140) benefit had been exhausted. You are also responsible for the difference between the billed amount and allowed amount because these services were received OON. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) or pay more for the simple extraction (D7140) provided on August 18, 2021, and August 19, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve tongue base volume reduction surgery (41530). 

 You asked the Plan to pre-approve surgical services. You say that this procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is not medically reasonable and 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 surgical services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the record indicates that the enrollee has sleep apnea.  The record does not indicate that the enrollee has failed conventional treatments such as a continuous positive airway pressure (CPAP) device and oral appliances. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 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 surgical services have not been met. Therefore, we decided that the Plan does not have to pre-approve tongue base volume reduction surgery (41530).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a specialist office visit (99213) to be provided by an out-of-network (OON) provider.  

You asked the Plan to pre-approve a specialist office visit. You say that this provider has been your provider for 3.5 years since you were first diagnosed. You also say that you feel that your case requires special attention and continuation of care, because the complications secondary to your cancer have required a certain expertise and skill level that can be delivered only from an oncologic surgeon. The Plan denied your request. The Plan says this provider is not an in-network provider. The Plan also says that there are six other in-network providers the enrollee can see.  

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 provider at issue in this case is not a network provider with the Plan. 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 a specialist office visit. Our reviewer says that the service is not reasonable or medically necessary. Our physician reviewer found this member with metastatic progressive colon cancer has no active surgical issues. Progressive metastatic colon cancer is mainly a cancer treated with systemic therapy and not surgery. He does not require continuous follow-up with surgery and an in-network surgeon is available.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a specialist office visit have not been met.   

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 a specialist office visit. Therefore, we decided that the Plan does not have to pre-approve a specialist office visit (99213) to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a temporary bladder catheter insertion provided on August 5, 2021.  

You asked the Plan to waive the copayment for the catheter insertion. You say that you feel that the $40 copayment should apply. The Plan denied your request. The Plan says the enrollee has been charged 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $300 copayment for outpatient surgery services.  

 The enrollee has been asked to pay $102.51, which is less than the $300 copayment for the catheter insertion. Please note that the record does not indicate a specialist office visit charge for August 5, 2021. The catheter insertion falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a temporary bladder catheter insertion provided on August 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a CT scan provided on September 3, 2021. 

 You asked the Plan to waive the copayment for a CT scan. You say that you were told that scan would be fully covered. 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 $200 copayment for diagnostic radiology services.   

You have been asked to pay the allowed amount of $172.93, which is less than the $200 copayment a CT scan. A CT scan falls within the outpatient diagnostic services and therapeutic services and supplies 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 a CT scan provided on September 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA) procedure.  You asked the Plan to pre-approve SI joint RFA services. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is considered experimental/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 SI joint RFA services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found According to the literature, 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.    Studies completed say that this procedure does not improve outcomes compared to standard treatment of SIJ pain.  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 SI joint RFA services have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA) procedure.
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 that the enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility.  

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: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prolia.  You asked the Plan to pre-approve Prolia. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.    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 Prolia. Our reviewer says that the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer found the enrollee has age related osteoporosis with high risk of fracture. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one alternatives of one oral bisphosphonate (such as alendronate, risedronate) and one intravenous bisphosphonate therapy (such zoledronic acid). The record indicates that the provider has confirmed that there is no contraindication to the preferred agents. Therefore, the enrollee does not meet criteria for the requested Prolia.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on March 24, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 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 laboratory services provided on March 24, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an Intracept procedure (22899, C9752).  You asked the Plan to pre-approve an Intracept procedure. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested procedure is experimental/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 an Intracept procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Intracept procedure is experimental. More research is needed to demonstrate the procedure's safety and efficacy.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure (22899, C9752).
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional mileage for routine transportation.  You asked the Plan to pre-approve additional mileage for routine transportation. You say that you want to see this provider. The Plan denied your request. The Plan says your benefit only allows 30 one-way trips with each one-way trip not exceeding 50 miles of driving distance.  Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation when the driving distance for a one-way trip is within 50 miles.   We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, the provider is located 57.3 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we decided that the Plan does not have to pre-approve additional mileage for routine transportation.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428) and ground mileage (A0425) provided on April 20, 2021.  

You asked the Plan to pay for the transportation services. You say that the enrollee's hospice election did not become effective until after the transport was complete. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428) and ground mileage (A0425) provided on April 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve expandable controller upgrade, electric connection between wheelchair and two or more controls, wheelchair harness upgrade, and power seat elevation system.  You asked the Plan to pre-approve expandable controller upgrade, electric connection between wheelchair and two or more controls, wheelchair harness upgrade, and power seat elevation system. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not medically necessary.  The Plan follows Medicare rules. Medicare rules say that power wheelchair accessories are only covered for certain indications.  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 expandable controller upgrade, electric connection between wheelchair and two or more controls, wheelchair harness upgrade, and power seat elevation system. Our reviewer says that the documentation does not support that the requested power wheelchair upgrades are medically reasonable or necessary. Our physician reviewer found the enrollee has asymmetric parkinsonism with significant rigidity and apraxia suggestive of corticobasal syndrome. The enrollee has three power options of tilt, recline, and power elevating leg rests but the enrollee does not need to control the power options through a joystick. The enrollee's upper extremity strength and function support that the enrollee can control any power options through their own switches. Therefore, the enrollee does not meet criteria for the requested items.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of expandable controller upgrade, electric connection between wheelchair and two or more controls, wheelchair harness upgrade, and power seat elevation system have not been met. Therefore, we decided that the Plan does not have to pre-approve expandable controller upgrade, electric connection between wheelchair and two or more controls, wheelchair harness upgrade, and power seat elevation system.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for genicular nerve block provided on July 2, 2021.  You asked the Plan to pay for genicular nerve block. You say that this is not experimental and meets coverage guidelines. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this genicular nerve block is considered investigational and 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 pay for genicular nerve block. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found genicular nerve blocks and radiofrequency ablations are considered investigational.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genicular nerve block have not been met. Therefore, we decided that the Plan does not have to pay for genicular nerve block provided on July 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870, C1821).  You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested procedure is experimental/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 a Vertiflex procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Vertiflex procedure is experimental. More research is needed to demonstrate the procedure's safety and efficacy.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870, C1821).