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

We decided that the Plan does not have to pay for OmniSeq Advance Panel testing provided on November 22, 2019.
You asked the Plan to pay for genetic tests. You say that you did not go for this testing and should not be held liable. The Plan denied your request. The Plan says the denial of payment for these tests is correct, because you did not meet the Medicare criteria for coverage of these tests. The Plan follows Medicare rules. Medicare rules say that genomic sequence analysis panels may be covered for enrollees who have advanced (Stage IIIB or IV) non-small cell lung cancer that meet certain criteria. 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 genetic tests. Our reviewer says that you do not meet the Medicare criteria for the testing performed. Our physician reviewer found this testing is indicated for locally advanced or metastatic non-small cell lung cancer. You had an early stage non-small cell lung cancer and, therefore, did not meet Medicare's coverage criteria. These tests were not medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Additionally, the Plan issued prior notice to you on November 7, 2019 that these tests would not be covered. Based on this information, we decided that Medicare rules for coverage of genetic tests have not been met. Therefore, we decided that the Plan does not have to pay for OmniSeq Advance Panel testing provided on November 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecomplete upper denture (D5110) and lower partial denture (D5214).You asked the Plan to pre-approvethe dental services. You say that your current upper denture is broken and falls out and your lower denture was lost 2 years ago and you are appealing so you can eat properly.The Plan denied your request. The Plan says this service is not covered under the 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, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvecomplete upper denture (D5110) and lower partial denture (D5214)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in bathtub (A9270).
You asked the Plan to pre-approve a walk-in bathtub. You say that you are requesting a simple walk-in shower. Having severe heart, kidney and respiratory disease it's only a matter of time until you end up with serious injuries. The Plan denied your request. The Plan says a walk-in bathtub is a convenience item and is not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a walk-in bathtub (A9270).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the BiPAP provided on January 7, 2020.You asked the Plan to waive the deductible for the BiPAP. You say that you don't think you owe the charge.The Plan denied your request. The Plan says you had not met your 2020 deductible at the time of the claim.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $300 deductible for covered services. The item or service you asked the Plan to waive the deductible for falls within the benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $300 deductible for covered services. This cost sharing is a contractual obligation that had not been met at the time the BiPAP was received on January 7, 2020.Therefore, we decided that the Plan does not have to waive the deductible for the BiPAP provided on January 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the endodontic therapy (D3330).You asked the Plan to pre-approve the endodontic therapy. You say that you are recommending saving the enrollee's tooth with a root canal, post and core buildup, and permanent crown. You also say that the enrollee does not want to extract the tooth and wear a partial denture.The Plan denied your request. The Plan says this service is not a covered benefit.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 pre-approve the endodontic therapy (D3330).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvephysician services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvephysician services. You say that you would like this claim approved for these services.The Plan denied your request. The Plan says there are in-network providers available for these services.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 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 these items/services.Therefore, we decided that the Plan does not have to pre-approvephysician services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair push handles.
You asked the Plan to pre-approve wheelchair push handles. You say that you need a manual wheelchair and accessories. The Plan denied your request. The Plan says the push handles are convenience items.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve wheelchair push handles.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOrcam (E1399).You asked the Plan to pre-approveOrcam. You say that with Orcam the enrollee will be able to seeThe Plan denied your request. The Plan says this device is not covered.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approveOrcam (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that in the past your orthotics have been covered and you are disappointed in the Plan's decision to deny authorization for new ones. You say that you have had issues with your back and lifting and carrying furniture was a direct cause of these problems. You stated that you need the requested orthotics to stabilize your back and reduce the pain that you experience. You say that you also have had issues with your hips and the requested orthotics would help a lot. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve upper partial-resin base (D5211).You asked the Plan to pre-approve the dental services. You say that you feel that this should be covered because you are having a hard time chewing and the $2,500 for dental work under your enhanced dental plan should be used to cover the partial.The Plan denied your request. The Plan says the requested service is not covered under the 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, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve upper partial-resin base (D5211).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral exam (D0140) cone beam CT scan (D0367), intraoral-periapical first x-ray (D0220)and intraoral-periapical each additional x-ray (D0230) provided January 20, 2020.
You asked the Plan to pay for the dental services. You say that as a result of this overcharge practice of doing business you request a full adjustment on all the charges that you were billed for during this visit. The Plan denied your request. The Plan says limited oral exams and cone beam CT scan is not covered under the plan benefits and the x-rays are limited to once a year, therefore the frequency limitation has been exceeded.
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 limited oral exam (D0140) cone beam CT scan (D0367), intraoral-periapical first x-ray (D0220)and intraoral-periapical each additional x-ray (D0230) provided January 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Bevacizumab, 10mg for the enrollee.You asked the Plan to pre-approve the drug. You say that this is medically necessary.The Plan denied your request. The Plan says the services were not considered medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found Bevacizumab is not FDA approved for metastatic non-small cell lung cancer that has progressed on first line EGFR therapy not is it supported by major drug compendia for off-label use or the medical literature. The provided clinical trial was a phase 1/2 trial looked at first line treatment in patients with metastatic NSCLC with the combination of osimertinib and bevacizumab. This patient has progressed on first line EGFR treatment. The service is not reasonable or medically necessary or deemed safe or effective 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 the drug have not been met.Therefore, we decided that the Plan does not have to pre-approve Bevacizumab, 10mg for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe transcatheter mitral valve repair provided on November 26, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says this is not medically necessary.The Plan follows Medicare rules. Medicare rules say that transcatheter mitral valve repairis covered when the criteria in the above NCD are met.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 topay for the services. Our reviewer says that the requested percutaneous transcatheter mitral valve repair did not meet the criteria for coverage. Our physician reviewer found that the enrollee has symptomatic severe mitral regurgitation, but the documentation does not support that coverage criteria are met. Specifically, the documentation does not support that "both a cardiothoracic surgeon experienced in mitral valve surgery and a cardiologist experienced in mitral valve disease have independently examined the patient face-to-face and evaluated the patient's suitability for mitral valve surgery and determination of prohibitive risk; and both surgeons have documented the rationale for their clinical judgment and the rationale is available to the heart team".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 forthe transcatheter mitral valve repair provided on November 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 24, 2019 and November 12, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 physician's services provided on October 24, 2019 and November 12, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on January 17, 2020.You asked the Plan to pay forthe assembly and operation of a pump with an oxygenator or heat exchanger. You say that this service was required.The Plan denied your request. The Plan says payment for this service is included in the DRG.The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission.Therefore, we decided that the Plan does not have to pay forthe assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on January17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on February 17, 2020.You asked the Plan to pay for the comprehensive periodontal evaluation. You say that you are enrolled in the Plan's optional dental benefit which includes some benefits for periodontal work. You also say that you do not understand how a dentist can provide periodontal surgery or periodontal maintenance without a periodontal evaluation first.The Plan denied your request. The Plan says this service is not covered under your contract under any normal circumstances.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 comprehensive periodontal evaluation (D0180) provided on February 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for digital breast tomosynthesis (77062) provided on February 21, 2020.
You asked the Plan to pay for the digital breast tomosynthesis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicare guidance says procedure 77062-26 has a status code of I.
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 CPT code 77062 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 77062 has a status code of I. This means that CPT code 77062 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the digital breast tomosynthesis have not been met. Therefore, we decided that the Plan does not have to pay for digital breast tomosynthesis (77062) provided on February 21, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on February 28, 2020.
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 claim was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for an independent laboratory; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on February 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two retainer crowns and four pontics.
You asked the Plan to pre-approve the retainer crowns and pontics. You say that the services are covered, and if you go over the amount of $3,000 you can pay the difference. The Plan denied your request. The Plan says these services are not covered under your dental coverage plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two retainer crowns and four pontics.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on December 9, 2019.You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says prior authorization was not received.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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe rehab shower commode chair (E1399).You asked the Plan to pre-approvethe rehab shower commode chair. You say that you need this equipment to be able to assist in the bathroom because a regular commode does not have wheels to be transferred from the bed to the toilet and to the shower.The Plan denied your request. The Plan says this service is not covered.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approvethe rehab shower commode chair (E1399)