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

We decided that the Plan does not have to pay for nail debridement provided by an out-of-network provider on December 22, 2020.
You asked the Plan to pay for the nail debridement. You say that the services should be considered separate and distinct services from any other date. You say that the claim should be processed for payment. The Plan denied your request. The Plan says this provider is not a network 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 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 nail debridement provided by an out-of-network provider on December 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor supply allowance provided on August 1, 2020.
You asked the Plan to pay for the continuous glucose monitor supply allowance. You say that the Plan should pay this claim. The Plan denied your request. The Plan says criteria is not met for a CGM therefore the supply allowance is not covered.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not using insulin with at least three daily injections nor requires frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM and
the supply allowance have not been met. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor supply allowance provided on August 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a tooth extraction (D7210) provided on October 13, 2020.
You asked the Plan to pay for the extraction. You say that you had this same issue regarding payment with this dentist a year ago and are having trouble getting reimbursement for this claim. The Plan denied your request. The Plan says they do not cover dental services received from a provider who has opted out of Original Medicare. The provider you used has chosen not to participate in Medicare, and therefore no payment can be provided.
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, items or services received from a provider who has chosen to opt out of Medicare are not covered under this benefit. Therefore, we decided that the Plan does not have to pay for a tooth extraction (D7210) provided on October 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on December 28, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you feel that you should not be held responsible for this bill. The Plan denied your request. The Plan says this service is not covered.
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 provided on December 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and resin-based composite provided on January 9, 2020, and May 11, 2020 by an OON provider.

You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and resin-based composite. You say that you were advised that this provider accepted your insurance. The Plan denied your request. The Plan says these services were rendered by a non-participating provider.

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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and resin-based composite provided on January 9, 2020, and May 11, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder Detect test (0012M) provided on October 22, 2020.

You asked the Plan to pay for the CxBladder Detect. You say that you would like reconsideration because this testing is medically necessary. The Plan denied your request. The Plan says this service does not meet Medicare's criteria of medically necessary and reasonable and cannot be approved.

The Plan must follow Medicare rules. Medicare rules say that for the CxBladder assay coded as 0012M, non-coverage was reaffirmed by Medicare.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CxBladder Detect have not been met. Specifically, this testing is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the CxBladder Detect test (0012M) provided on October 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is necessary. The Plan denied your request. The Plan says the stay is not necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement however, the documentation does not support that the enrollee would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehab services fifteen (15) hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain their functional status. The enrollee is ambulating household distances with minimal assistance. The enrollee is near her prior level of function and could receive services at a lower level of 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 8, 2021.
You asked the Plan to pay for the physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
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 physician's services. 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 physician's services provided on January 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a duplex scan (93880) and ultrasound of the heart (93306).

You asked the Plan to pre-approve a duplex scan (93880) and ultrasound of the heart (93306). You say that the requested duplex scan (93880) and ultrasound of the heart (93306) are medically necessary. The Plan denied your request. The Plan says the requested duplex scan (93880) and ultrasound of the heart (93306) are 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 pre-approve a duplex scan (93880) and ultrasound of the heart (93306). Our reviewer says that the requested duplex scan (93880) and ultrasound of the heart (93306) are not medically necessary. Our physician reviewer found the enrollee is stable without new symptoms of cardiovascular or cerebrovascular disease. His exam also does not show signs of congestive heart failure or carotid disease. Regarding the echocardiogram, his last two echos are normal and there is a report of another done (report not included) all of which report normal and unchanged LV function since his MI. Given the lack of any new symptoms or signs of heart disease and the multiple normal and unchanged echocardiograms since his MI, repeat echocardiography would not be medically reasonable or necessary at this time per AHA/ACC appropriate use guidelines and would therefore not meet the criteria of the applicable CMS Section 1862(a) medical necessity rule.

With regard to the requested carotid duplex ultrasound study, in the absence of signs or symptoms of cerebrovascular disease or prior documented carotid artery disease, carotid duplex ultrasound would be considered a screening procedure and would therefore not meet the applicable CMS LCD 35397 criteria for its use in this situation.

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 duplex scan (93880) and ultrasound of the heart (93306) have not been met. Therefore, we decided that the Plan does not have to pre-approve a duplex scan (93880) and ultrasound of the heart (93306).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on October 15, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-network.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on October 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Sanexas neoGen-Series Therapy (electrical cell stimulation) provided October 12, 2020.
You asked the Plan to pay for Sanexas neoGen-Series Therapy. You say that you disagree with the decision and is submitting medical records demonstrating the medical necessity of this service and documents proofing that these services are not experimental/investigational. The Plan denied your request. The Plan says these procedures are considered investigational as there is not enough scientific evidence supporting that this treatment is effective.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Sanexas neoGen-Series Therapy have not been met. Therefore, we decided that the Plan does not have to pay for Sanexas neoGen-Series Therapy (electrical cell stimulation) provided October 12, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the special service or report services provided from June 19, 2020, to August 21, 2020.
You asked the Plan to pay for the special service or report services. You say that you are on a fixed income and would like these services to be covered. The Plan denied your request. The Plan says the treating provider does not participate in Medicare.
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items or services, a provider or supplier must be enrolled in the Medicare program. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the special service or report services have not been met. This provider is not part of the Medicare program and is not payable. Therefore, we decided that the Plan does not have to pay for the special service or report services provided from June 19, 2020, to August 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tecentriq Solution 840MG/14ML, for the enrollee.

You asked the Plan to pre-approve the medication. You say that the requested treatment with Tecentriq combined with Avastin is medically necessary. The Plan denied your request. The Plan says the requested treatment with Tecentriq combined with Avastin is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 the medication. Our physician reviewer found the requested use of Tecentriq is not FDA-approved for the enrollee's diagnosis, as not first line given prior Lenvatinib. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal (see appendix for list of CMS-approved journals).

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 medication have not been met. Therefore, we decided that the Plan does not have to pre-approve Tecentriq Solution 840MG/14ML, for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction provided on January 4, 2021.
You asked the Plan to pay for the extraction. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service is not covered. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.
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 extraction provided on January 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (CPT 71045) provided to the enrollee on May 28, 2020.
You asked the Plan to pay for the services. You say that the claim denied as duplicate in error. The Plan denied your request. The Plan says the services provided were denied, as they are bundled to another service billed on the same day by the same physician.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 71045 is "Radiologic examination, chest." We asked our coding 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 the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found CPT 71045 is bundled into CPT 77001 which was billed on the same date of service. Both CPT 71045 and CPT 77001 were reported with modifier 26, professional component. Since both CPT 71045-26 and CPT 77001-26 were billed on the same day without documentation that supports a distinct procedural service, CPT 71045 is considered a duplicate claim. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (CPT 71045) provided to the enrollee on May 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Sanexas neoGen-Series electrical stimulation therapy (97032 and 97112), Vasopneumatic device therapy (97016) and the subcutaneous injection of FDA Nutri-Pharmaceutical blend provided on October 7, 2020.
You asked the Plan to pay for the Sanexas neoGen-Series electrical stimulation therapy, Vasopneumatic device therapy and subcutaneous injection of FDA Nutri-Pharmaceutical blend.. You say that you would like reconsideration because these services were medically necessary. The Plan denied your request. The Plan says these services are considered to be 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 pay for the Sanexas neoGen-Series electrical stimulation therapy, Vasopneumatic device therapy and subcutaneous injection of FDA Nutri-Pharmaceutical blend.. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical literature does not contain sufficient evidence supporting the use of the Sanexas neoGen-Series electrical stimulation therapy, Vasopneumatic device therapy, and the subcutaneous injection of a nutria-pharmaceutical blend/mix. The therapies at issue in this case are not accepted standards of medical practice, and it has not been demonstrated that the therapies are at least as effective as existing medically appropriate alternatives.
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 Sanexas neoGen-Series electrical stimulation therapy, Vasopneumatic device therapy and subcutaneous injection of FDA Nutri-Pharmaceutical blend. have not been met. Therefore, we decided that the Plan does not have to pay for Sanexas neoGen-Series electrical stimulation therapy (97032 and 97112), Vasopneumatic device therapy (97016) and the subcutaneous injection of FDA Nutri-Pharmaceutical blend provided on October 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient mental health stay provided by a participating provider on April 6, 2019, to April 8, 2019.
You asked the Plan to waive the copayment for an inpatient mental health stay. You say that you did not go in because of symptoms of mania. You say that it is not fair that they would even say that. 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 $230 copayment per day for days 1-7. There is a $0 copayment for additional days for inpatient mental health care. You have been asked to pay a $230 copayment per day for days 1-2 for an inpatient mental health stay. The total amount you are being asked to pay is $460 ($230 x 2 days = $460). Since inpatient mental health services were provided, the correct copayment has been applied. An inpatient mental health stay falls within the inpatient mental health 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 an inpatient mental health stay provided by a participating provider on April 6, 2019, to April 8, 2019.