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

We decided that the Plan does not have to pay for the Comprehensive Genomic Profile (CGP) testing provided on September 11, 2020.
You asked the Plan to pay for the CGP testing. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
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 various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have to pay for the Comprehensive Genomic Profile (CGP) testing provided on September 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the non-emergency transportation; encounter/trip 
(T2003 x 2) provided on June 30, 2020. 
 
You asked the Plan to reimburse you for the ambulance services. You say that the enrollee was not able to sit, 
stand and walk to utilize personal transportation. You say that the enrollee passed away 2 months after the 
doctor appointment. You say that this shows that the appointment was necessary for the enrollee to receive the 
attention he so required. The Plan denied your request. The Plan says ambulance trips to and from the doctor's 
office are only covered under special circumstances. The Plan also says that the ambulance services in this case 
are 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 reimburse you for the ambulance services. Our 
reviewer says that the ambulance services was not medically necessary. Our physician reviewer found the 
provided documentation did not show that stretcher van or wheelchair van would be contraindicated. The 
reviewer found that the documentation did not show that the enrollee required special equipment or staff during 
transport to a non-emergent doctor's office visit. Therefore, the reviewer found that this request for ambulance 
services on June 30, 2020, was not medically necessary based on the documentation provided. 
 
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 ambulance services have not been met. Specifically, the record did not 
indicate that a stretcher van or wheelchair van would be contraindicated. Therefore, we decided that the Plan 
does not have to reimburse you for the non-emergency transportation; encounter/trip (T2003 x 2) provided on 
June 30, 2020
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a transcatheter aortic valve replacement (TAVR) procedure.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that there was no information on the expectation of your quality of life.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 the requested services. Our physician reviewer found that although generally indicated for severe aortic stenosis, TAVR has been used successfully in specific situations for severe aortic insufficiency. In this instance, you continue to have significant congestive heart failure symptoms despite medical therapy and an implanted left ventricular assist device (LVAD) and severe aortic insufficiency, which has developed since the LVAD was initially placed. You also have significant right ventricular dysfunction which, in the opinion of the surgical consultant, would make open surgery with aortic valve replacement very high risk, especially since it would also be a second operation in her chest. Given the significant limiting co-morbidities and the clinical situation, along with the assessment of the surgical and medical consultants, TAVR as an off-label indication, appears medically reasonable and necessary in this specific set of clinical circumstances. 

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 requested services have been met. Therefore, we decided that the Plan has to pre-approve a transcatheter aortic valve replacement (TAVR) procedure.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a participating provider on April 14, 2021.
You asked the Plan to waive the copayment for a specialist office visit. You say that you did not see a specialist. The Plan denied your request. The Plan says the correct copayment has been applied.
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 physician/practitioner services/in-network/specialty care.
You have been asked to pay a $45 copayment for a specialist office visit. The physician that provided these services is considered a specialist; therefore, the correct copayment has been applied. A specialist office visit falls within the physician/practitioner services/in-network/specialty 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 a specialist office visit provided by a participating provider on April 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation and preventive procedure provided on March 16, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation and preventive procedure. You say that you do not understand why these services were denied and would like them to be reviewed. The Plan denied your request. The Plan says these services are not covered. The Plan also says that the provider's office advised that you signed a pay agreement with the office for these 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 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 problem focused limited oral evaluation and preventive procedure provided on March 16, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued home health services.
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says you have no skilled needs.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.
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 continued services. Our physician reviewer found that you do not have documented skilled nursing or skilled therapy needs. Your care needs are custodial and long-term. As such, the requested home health services are not shown to be 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 continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued home health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648) provided on April 29, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for a lumbar-sacral orthosis. You say that you are an accredited facility and the equipment for the member was provided in good faith. The Plan denied your request. The Plan says services were provided 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 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 a lumbar-sacral orthosis (L0648) provided on April 29, 2020, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the acetaminophen, oxycodone, and meloxicam provided in an outpatient setting on March 15, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you already paid your copayment for the outpatient surgery. You also say that you would like the surgery related charge to be covered. The Plan
denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.
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 pay for the acetaminophen, oxycodone, and meloxicam provided in an outpatient setting on March 15, 2021.
Benefits for the self-administered drugs 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the comprehensive oral evaluation (D0150), complete lower denture (D5120) and upper partial denture (D5213).
You asked the Plan to pre-approve the comprehensive oral evaluation (D0150), complete lower denture (D5120) and upper partial denture (D5213). The Plan denied your request. The Plan says the benefits for each service have 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.
Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of one comprehensive oral evaluation every 3 years and one set of dentures every 5 years. The Plan paid for a comprehensive oral evaluation provided June 30, 2021 and a set of partial dentures provided on January 22, 2019, which exhausted your benefits. Therefore, we decided that the Plan does not have to pre-approve the comprehensive oral evaluation (D0150), complete lower denture (D5120) and upper partial denture (D5213).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Actemra (J3262).

You asked the Plan to pre-approve Actemra. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the use of the requested drug is off-label and not medically accepted.

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 Actemra. Our reviewer says that the requested treatment is not medically reasonable and necessary in this case. Our physician reviewer found that the record indicates that the enrollee has iritis. The Food and Drug Administration has not approved the requested drug for the noted indication. The Medicare-approved compendia do not contain a positive citation for the requested drug for the noted indication. 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 Actemra have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Actemra (J3262).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for radiofrequency ablation of the nerves innervating the sacroiliac joint (64625) provided on March 23, 2021.
You asked the Plan to pay for radiofrequency ablation of the nerves innervating the sacroiliac joint. You say that this was medically necessary. The Plan denied your request. The Plan says this is experimental.
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 radiofrequency ablation of the nerves
innervating the sacroiliac joint. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found radiofrequency ablation of the sacroiliac joint is considered experimental because of the wide variation in reported effectiveness. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation of the nerves innervating the sacroiliac joint have not been met. Therefore, we decided that the Plan does not have to pay for radiofrequency ablation of the nerves innervating the sacroiliac joint (64625) provided on March 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Coronavirus antibody testing rendered on February 19, 2021 to February 21, 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 testing was 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 these services. Our reviewer says that the
testing was not medically necessary. Our physician reviewer found the submitted records do not contain specific clinical rationale for the Coronavirus antibody testing. There is no documentation to indicate that the testing was reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the Coronavirus antibody testing rendered on February 19, 2021 to February 21, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a capsule endoscopy.
You asked the Plan to pre-approve gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), esophagus through ileum, with interpretation and report (91110). You say that the capsule endoscopy is crucial to rule out small bowel cancer. The Plan denied your request. The Plan says capsule endoscopy is not a Medicare benefit for colorectal cancer screening.
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, gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), esophagus through ileum, with interpretation and report (91110), is being 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 pre-approve a capsule endoscopy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower
denture (D5214).

You asked the Plan to pre-approve the dental services. You say that you need dentures. The Plan denied your
request. The Plan says dentures are not 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, dentures are not listed in the office
reference manual under your specific plan as covered services. The Evidence of Coverage states that additional
coverage for preventive and comprehensive dental services can be provided through the Plan's Flex Benefit.

The record shows that the Flex Benefit has been used up prior to your request for these services. Therefore, we
decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower
denture (D5214).
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the periodic oral exam (D0120), periapical x-rays (D0220, D0230), bitewing x-rays (D0274) and dental cleaning (D1110) provided on March 30, 2021.

You asked the Plan to pay for the preventative dental care. You say that these services are covered by the Plan's dental benefit. The Plan denied your request. The Plan says that you have opted out of participation with Medicare, and therefore no payment can be made.

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.

We looked at the file and Medicare rules. The Plan's contract lists all the services in question as covered services. Payment for this care was denied on the basis that you are an out-of-network provider that has also opted-out of Original Medicare. Normally, providers who have opted-out of Medicare are unable to receive payments from Medicare plans for medical services. However, the Centers for Medicare and Medicaid Services (CMS) has stated that opt-out provisions do not apply to supplemental benefits unless the Plan specifically states this limitation in the contract. Dental services are not covered by Medicare and are instead covered by a supplemental benefit offered by the Plan. Opt-out rules do not prevent a provider from being paid for non-Medicare covered benefits.

The Plan's contract does not state that dental care must only be received from a provider who participates in Original Medicare. It does state that services must be received from a licensed dentist. The Plan's contract also states that enrollees may choose to visit an out-of-network provider. However, it is noted that an enrollee may pay more for services from an out-of-network provider, as the Plan will pay the full allowed amount for the service which may be less than what is billed by the provider. There is no contract limitation that states that an enrollee cannot see a provider who has opted-out of original Medicare or that they cannot see an out-of-network dentist.

Based on this information, we decided that the Plan's rules for coverage of the preventative dental care have been met. Therefore, we decided that the Plan has to pay for the periodic oral exam (D0120), periapical x-rays (D0220, D0230), bitewing x-rays (D0274) and dental cleaning (D1110) provided on March 30, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray of the shoulder (73030) provided on February 15, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for an x-ray of the shoulder. You say that the services should be covered as an emergency. The Plan denied your request. The Plan says the provider at issue is not contracted with the Plan for medical services, there was no authorization on file and no referring 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 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 x-ray of the shoulder (73030) provided on February 15, 2021, by an out-of-network (OON) provider.