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

We decided that the Plan does not have to pay for the scaling in presence of generalized gingival inflammation (D4346) provided on August 3, 2020.
You asked the Plan to pay for the dental service. You say that you advised the dental office which dental coverage you had. You say that you were advised that after the service was completed, they also did a scaling. You say that you told them that was not a covered service. You say that the provider said they would take care of it later. You also say that the provider did nothing different that they normally do during the procedure. The Plan denied your request. The Plan says dental coverage is limited to preventive services. The Plan says that periodontal scaling is not considered to be a basic or preventive 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 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 scaling in presence of generalized gingival inflammation (D4346) provided on August 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network chiropractor.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are available from network providers.
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 rules say that
Medicare does not cover naturopathic services.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide Medicare-covered chiropractic manipulation services. We found no exception that
would require the Plan to pre-approve these items/services. The requested holistic/naturopathic services are not
covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve a referral to
an out-of-network chiropractor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthoses (L0650, L1851, L2397) provided August 19, 2020.
You asked the Plan to pay for the orthoses. You say that the items were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed items.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery, and sufficient medical records to support the items. The record does not contain sufficient medical records which support medical necessity for the supplies provided in this case. There is no documentation of a physical exam and no documentation of recent injury, surgery, or joint laxity. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for orthoses (L0650, L1851, L2397) provided August 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 64999) provided on October 7, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed incorrectly.
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 64999 is not supported in the medical record. Specifically, it is inappropriate to bill CPT 64999 for anesthesia services provided by an anesthesia practitioner. CPT codes 00100-01999 should be used for anesthesia services provided by an anesthesia practitioner. 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 services (CPT 64999) provided on October 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for prescription drugs provided by a participating provider on October 1, 2020.

You asked the Plan to waive the coinsurance for prescription drugs. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for Medicare Part B prescription drugs.

You have been asked to pay a 20% coinsurance of the allowed amount for prescription drugs. The total allowed amount is $735. The total amount you are being asked to pay is $147 ($735 x 20% = $147). Prescription drugs fall within the Medicare Part B prescription drugs 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 coinsurance for prescription drugs provided by a participating provider on October 1, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital day discharge management provided on November 21, 2019.

You asked the Plan to pay for the physician service. You say that the service should be covered. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the hospital day discharge management provided on November 21, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 10 physical therapy (PT) sessions.

You asked the Plan to pre-approve the additional PT sessions. You say that the enrollee's condition is not yet to the point where she is able to teach her dance classes which she relies on for income. It is felt that she will be able to progress to being able to do this with further treatment. The Plan denied your request. The Plan says the requested additional physical therapy visits are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

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 additional PT sessions. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for the patient's condition beyond what was approved by the health plan. The patient has had extensive prior therapy for this condition and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The patient has been instructed in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration.

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 additional PT sessions have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional 10 physical therapy (PT) sessions.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the abutment supported crown (D6059) and the prefabricated abutment (D6056) provided on November 30, 2020.
You asked the Plan to pay for the dental services. You say that the implant was medically appropriate. You say say that a bridge would destroy 2 healthy teeth on either side. The Plan denied your request. The Plan says abutment supported crown is not listed and therefore is not a covered service. The Plan says that prefabricated abutment is not listed as a covered service either.
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. The Evidence of Coverage clearly states that any services not listed are not covered. Therefore, we decided that the Plan does not have to pay for the abutment supported crown (D6059) and the prefabricated abutment (D6056) provided on November 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four gingival irrigations (D4921 x4) and two drugs or medicaments dispensed in the office for home use (D9630 x2) provided on September 30, 2020.

You asked the Plan to pay for the gingival irrigations and drugs or medicaments. You say that you feel you should not be held responsible for these charges. The Plan denied your request. The Plan says these services are not covered benefits under your dental 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 pay for the four gingival irrigations (D4921 x4) and two drugs or medicaments dispensed in the office for home use (D9630 x2) provided on September 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Coflex procedure.

You asked the Plan to pre-approve a Coflex procedure. You say that the requested Coflex procedure is medically necessary. The Plan denied your request. The Plan says the requested Coflex procedure is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Coflex procedure. Our reviewer says that the requested Coflex procedure is not medically necessary. Our physician reviewer found the enrollee is with spinal stenosis related pain. The Coflex device is experimental. More research is needed to show safety and efficacy. There is no instability documented. Hardware not needed. 

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 Coflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Coflex procedure.
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 these orthotics are medically necessary. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device.

You asked the Plan to pre-approve the Vertiflex Superion device. The Plan denied your request. The Plan says this is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Vertiflex Superion device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Vertiflex device is experimental. More research is needed to show safety and efficacy of the procedure.

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 Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on July 10, 2020.

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 the services were billed incorrectly.

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 G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on July 10, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
You asked the Plan to pre-approve the CGM. You say that you feel that the coverage rules are met because the
enrollee needs to test between 4 and 9 times per day to manage their condition. The Plan denied your request.
The Plan says criteria are not met.
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 use insulin
with at least three daily injections. Only one page of medical records was submitted by the provider to support
the need for the CGM. This page does not offer any evidence regarding the use of insulin, which is required for
Medicare coverage of the CGM. Therefore, we decided that the Plan does not have to pre-approve a therapeutic
continuous glucose monitor (CGM).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided from October 13, 2020, to October 30, 2020.
You asked the Plan to waive the copayment for SNF care. You say that you were only in the facility for 17 days, and your benefits show a $0 copay for the first 20 days. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $0 copayment each day for days 1 to 20, and a $75 copayment per day for days 21 to 100 for Skilled Nursing Facility (SNF) Care up to an in-network maximum out-of-pocket amount of $2,400 for 2020. At the time this claim was processed, $1,553.52 of the $2,400 in-network maximum out-of-pocket amount had been met. This SNF stay lasted 17 days, which were days 19 to 35 of the benefit period, resulting in a total copayment amount of $846.48 because this amount, along with other cost-sharing amounts you have been asked to pay, met the $2,400 in-network maximum out-of-pocket amount for 2020. You have been asked to pay a $0 copayment each day for days 1 to 20, and a $75 copayment per day for days 21 to 100 for SNF care. SNF care falls within the Skilled Nursing Facility (SNF) 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 skilled nursing facility (SNF) care provided from October 13, 2020, to October 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Formoterol fumarate (J7606) provided on January 15, 2020.

You asked the Plan to waive the coinsurance for Formoterol fumarate. You say that you are not aware of the supplier company. The Plan denied your request. The Plan says the correct coinsurance was 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 20% coinsurance for Part B drugs.

You have been asked to pay $112.92, or 20% of the Medicare-allowed amount of $564.60, for Formoterol fumarate. Formoterol fumarate falls within the "Medicare Part B prescription drugs" 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 coinsurance for Formoterol fumarate (J7606) provided on January 15, 2020.

Your complaint about the supplier's bill providing inadequate information to identify the transaction is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on September 16, 2020.
You asked the Plan to pay for the dental service. You say that you had an emergency extraction. You also say that this should be covered. The Plan denied your request. The Plan says the extraction is dental in nature. The Plan also says that extractions are not covered by Medicare.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the surgical extraction (D7210) provided on September 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the requested out-of-network provider.

You asked the Plan to pre-approve the physician's services. You say that you have been using this OB/GYN for many years and she is the physician that you have the most health history with and she knows all your medical issues and you do not want to experience additional panic and anxiety with losing another provider. The Plan denied your request. The Plan says there are in-network providers available to provide the requested 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by the requested out-of-network provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Abraxane (Paclitaxel protein-bound particles).

You asked the Plan to pre-approve Abraxane. You say that this request is medically necessary. The Plan denied your request. The Plan says step therapy criteria has not been met.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Abraxane. Our reviewer says that the request is not medically necessary and reasonable. Our physician reviewer found the enrollee has a diagnosis of metastatic squamous cell carcinoma of the lung. In this case, the Plan requires a trial of Taxol or Taxotere before they will approve the requested drug. The case file does not contain documentation of trial and failure of Taxol (Paclitaxel) or Taxotere (Docetaxel). In addition, the documentation does not support that Taxol (Paclitaxel) or Taxotere (Docetaxel) would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Abraxane have not been met. Therefore, we decided that the Plan does not have to pre-approve Abraxane (Paclitaxel protein-bound particles).