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

We decided that the Plan does not have to pay for out of network physician services provided from January 4, 2021 to April 29, 2021.  You asked the Plan to pay for these services. You say that these services should be covered by the Plan as neither you nor the provider were aware this office was not in network. The Plan denied your request. The Plan says the contract is clear that enrollees and providers are responsible for being aware of a provider's status.  
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 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 out of network physician services provided from January 4, 2021 to April 29, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for medical services you had at a cardiologist's office on December 16, 2020.  You asked the Plan to waive the copayment for the cardiology services. You say that you did not see the doctor on this date.  You said that you had the procedure done at the cardiology office because it was ordered by your doctor.  You said that you do not believe a copayment is required. 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 $45 copayment for provider and professional services in a specialist's office.   You have been asked to pay a $45 copayment for the cardiology services. According to your Evidence of Coverage, this copayment applies to any provider or professional services you receive in a specialist's office, even if you do not see a doctor.  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 medical services you had at a cardiologist's office on December 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on April 20, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.  The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.   We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. 
However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 the drug testing services provided on April 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) and retainer crown - porcelain/ceramic (D6740) provided June 3, 2021.  
You asked the Plan to pay for the intraoral x-ray and retainer crown. You say that the Plan should provide coverage because these services were needed to perform other covered procedures. The Plan denied your request. The Plan says you have exceeded the frequency limit for intraoral x-rays and retainer crowns are not covered under your 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. 
The Plan covers the intraoral x-ray once per year.  We looked at the file and Medicare rules. In this case the Plan provided documentation showing that an intraoral x-ray (D0220) was previously covered on May 26, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the intraoral x-ray has been exceeded. Though the Plan offers dental benefits in excess of Medicare coverage, the retainer crown is not among those covered services. Therefore, we decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) and retainer crown - porcelain/ceramic (D6740) provided June 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for Caris MPI biomarker testing for the enrollee.  You asked the Plan to pre-approve the referral. You say that this testing is a critical component of cancer care, and instrumental in decoding cancer to better understand the biology driving tumor growth. 
The Plan denied your request. The Plan says there is a participating laboratory that can provide similar or identical testing for the biopsy diagnosis of cancer.  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 referral. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found next generation sequencing (NGS) has become a standard of care in the treatment of many cancers. Results help guide clinical decision making. There are multiple companies that offer NGS and there is no rationale provided why the in-network testing would not be sufficient. The service is not reasonable or 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 referral have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an out-of-network referral for Caris MPI biomarker testing for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for subsequent nursing facility care provided on April 6, 2021.  You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says that in most cases, care received from an out-of-network provider will not be covered, with the following three exceptions: emergency care or urgently needed services, Medicare covered medical care that the providers in our network cannot provide, and dialysis services at a Medicare certified dialysis facility when the enrollee is temporarily outside the plan's service area. A prior authorization is required for non-emergency 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 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 subsequent nursing facility care provided on April 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve at the in-network benefit level the computed tomography (CT) scan of the pelvis to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve at the in-network benefit level the CT scan services. You say that you believe that the out-of-network (OON) provider has better equipment. The Plan denied your request. The Plan says they have multiple in-network providers available to provide the medical care you need. In addition, the Plan has stated that you may use the POS benefit to receive services from the OON provider.  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 at the in-network benefit level 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 at the in-network benefit level these items/services. Therefore, we decided that the Plan does not have to pre-approve at the in-network benefit level the computed tomography (CT) scan of the pelvis to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health services provided to the enrollee from June 14, 2020, to June 18, 2020.  You asked the Plan to pay for home health services. You say that previous claims were paid when billed this way. The Plan denied your request. The Plan says this was not billed correctly.  The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.  We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the record does not show that a RAP was submitted for these services. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from June 14, 2020, to June 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power operated vehicle (K0812).  You asked the Plan to pre-approve a power operated vehicle. You say that the requested item is a medical necessity for you. The Plan denied your request. The Plan says medical necessity rules for power mobility devices have not been met.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   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 power operated vehicle. Our reviewer says that the requested item is not medically reasonable and necessary in this case. Our physician reviewer found that the documentation does not indicate if you require the power operated vehicle for mobility-related self-care tasks within the home. There are no physical exam findings to support that you are unable to use a cane or a walker.  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 power operated vehicle have not been met. Therefore, we decided that the Plan does not have to pre-approve a power operated vehicle (K0812).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) services you received from June 28, 2021, to July 1, 2021.  You asked the Plan to waive the copayment for the ER services. 
You say that you were admitted to the hospital, so there should be no charge. 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 $120 copayment for emergency room services. You do not pay the emergency room visit cost share if you are admitted to the hospital within 24 hours.  You have been asked to pay a $120 copayment for the ER services. According to the billing records, you were not admitted to the hospital as an inpatient.  Rather, you were kept in observation for several days.  
Observation is considered an outpatient status and is not an inpatient admission.  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 emergency room (ER) services you received from June 28, 2021, to July 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Privigen.
You asked the Plan to pre-approve Privigen. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Privigen. Our reviewer says that the criteria for coverage of Privigen have not been met. Our physician reviewer found based on the medical records provided and review of the Medicare-approved major drug compendia, the requested use of Privigen is not FDA-approved for the enrollee's diagnosis. The use of Privigen for neurosarcoid is not supported by any of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 Privigen have not been met. Therefore, we decided that the Plan does not have to pre-approve Privigen.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the patient needs inpatient acute rehab and to have
experts to help with the left knee and learning how to take care of his thumb. The Plan denied your request. The
Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for peripheral artery
disease and had a below the knee amputation. The enrollee's medical conditions are stable. There are no
medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and
an intensive rehabilitation therapy program. While the medical record documents a need for physical and
occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive
rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for teeth # 22 and 23.
You asked the Plan to pre-approve the dental service. You say that the enrollee is in need of implants in order to avoid further bone atrophy. You say that this will add stability and retention to the enrollee's denture. You also say that this will avoid a nutritional disorder for the enrollee. The Plan denied your request. The Plan says core build up is not listed as a covered service.
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 core build up is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core build up (D2950) for teeth # 22 and 23.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Tremfya 100 mg/mL injection.  You asked the Plan to pre-approve Tremfya. You say that this requested drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says drug coverage is limited only to those drugs covered under the enrollee's medical benefit.  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 Tremfya 100 mg/mL injection.   Benefits for Tremfya 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services (99600) provided from January 5, 2021, to January 28, 2021.  You asked the Plan to pay for the home health services. You say that the services should be covered. The Plan denied your request. The Plan says the provider in this case is not certified for Medicare. The Plan also says that while the enrollee can get care from out of network providers, they must participate in Medicare.  The Plan must follow Medicare rules. 
The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the home health services (99600) provided from January 5, 2021, to January 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation - per site (D7953) provided June 29, 2021.  You asked the Plan to pay for the bone replacement graft. You say that the procedure was medically necessary, and you would expect partial reimbursement. The Plan denied your request. The Plan says this service is not covered under your 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, 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 bone replacement graft for ridge preservation - per site (D7953) provided June 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the spinal canal and contents (72148)  You asked the Plan to pre-approve MRI services. 
You say that the requested MRI services are medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.  
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI services. Our reviewer says that the requested MRI services are not medically reasonable and necessary. 
Our physician reviewer found that you are a 75-year-old male who presented with numbness and tingling due to diabetic neuropathy. You reported falling a few months ago and were in the hospital and since then has had numbness in feet. Exam showed reduced reflexes and sensory of bilateral lower extremities. You were also diagnosed with lumbosacral radiculopathy. The records do not clearly show positive provocative testing results to show a red flag diagnosis and there was no report of the patient having exhausted first line treatment for radiculopathy namely physical therapy, home exercises, and non-steroidal anti-inflammatory drugs. Therefore, without sufficient support made for MRI lumbar spine, it will be considered not medically necessary at this time and based on provided documentation.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MRI services have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the spinal canal and contents (72148)