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

We decided that the Plan does not have to pay for the unspecified preventive service (D1999), the prefabricated
abutment (D6056 x 3), and the abutment supported crown (D6058 x 3) provided on November 18, 2020.
You asked the Plan to pay for the dental services. You say that your dentist advised that your crowns were
fractured and recommended replacement. You say that the new crowns were installed properly. You also say
that these were not implants, but replacement crowns and they should be covered. The Plan denied your
request. The Plan says the dental services you received are not listed as covered services. The Plan also says
that any services not listed are 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
unspecified preventive service (D1999), the prefabricated abutment (D6056 x 3), and the abutment supported
crown (D6058 x 3) provided on November 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture (D5110) and complete
mandibular denture (D5120) provided on January 22, 2021.

You asked the Plan to pay for the complete maxillary denture and complete mandibular denture. You say that
you believe the $500 dental allowance you are allotted should have been applied toward these services. 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
complete maxillary denture (D5110) and complete mandibular denture (D5120) provided on January 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve L2397) provided October 9, 2020.
You asked the Plan to pay for the orthoses. You say that the plan is now in possession of all documents necessary to make a determination regarding the medical necessity of the services rendered. The Plan denied your request. The Plan says the services are not documented in the enrollee's medical records and the supporting documentation does not match the information sent on the claim.
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 orthoses. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. The documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and 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 the orthoses have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve L2397) provided October 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on November 11, 2020, to December 29, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you asked the Plan to tell you what doctor you could use. You say that this problem was never solved. You say that you only switched because you were told you could use the same doctors. The Plan denied your request. The Plan says prior authorization was not obtained by a participating 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. 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 physician services provided on November 11, 2020, to December 29, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bitewings - four films (D0274), intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), prophylaxis - adult (D1110), comprehensive oral evaluation - new or established patient (D0150), and topical fluoride varnish (D1206) provided September 22, 2020.

You asked the Plan to pay for bitewing x-rays, intraoral x-rays, dental cleaning, oral evaluation, and fluoride. You say that the Plan would have to pay less for the OON provider than if you went in-network. The Plan denied your request. The Plan says the services were provided OON and therefore are 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. The Plan covers bitewing x-rays, intraoral x-rays, dental cleaning, oral evaluation and fluoride when they are provided by a network provider.

We looked at the file and Medicare rules. You received dental services from an out-of-network provider. The Plan has network providers available who can provide the services at issue in this appeal. Based on this information, we decided that the Plan's rules for coverage of bitewing x-rays, intraoral x-rays, dental cleaning, oral evaluation and fluoride have not been met. Therefore, we decided that the Plan does not have to pay for bitewings - four films (D0274), intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), prophylaxis - adult (D1110), comprehensive oral evaluation - new or established patient (D0150), and topical fluoride varnish (D1206) provided September 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that this is medically necessary to decrease fall risk and improve quality of life for the enrollee. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetic shoes and multiple density inserts provided on October 20, 2020.
You asked the Plan to pay for diabetic shoes (A5500) and multiple density inserts (A5512). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. The supplier is not a Medicare certified DME supplier and therefore not eligible to receive payment.
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. The rules state that no Medicare payment may be made for items provided directly by a provider who is not eligible to take Medicare payment. The record does not contain a valid physician order, proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. The physician order does not contain the procedure codes and the medical records do not mention the need for orthotics. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. The items at issue in this appeal were provided by a provider not certified by Medicare. 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 diabetic shoes and multiple density inserts provided on October 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive cardiovascular panel (81286, 81407, 81408, 81479) provided on October 14, 2020.

You asked the Plan to pay for a comprehensive cardiovascular panel. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. 

We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a comprehensive cardiovascular panel have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive cardiovascular panel (81286, 81407, 81408, 81479) provided on October 14, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the problem focused limited oral evaluation provided on December 22, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you believe this service should be covered because you were referred by your dentist. The Plan denied your request. The Plan says that the service was rendered by a Medicare opt out provider. The Plan also says that prior to receiving the service you were advised by the provider that they did not participate in Medicare plans.
The Plan must follow Medicare rules. Medicare rules say that the health plan must provide you with a clear and accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under your plan contract including applicable conditions and limitations and any other conditions associated with the use or receipt of the benefits. The EOC states that you have an annual combined allowance of $1,000 for supplemental preventive and comprehensive services each year. The record does not show that you have exhausted this benefit for the 2020 plan year. Your EOC does not state that services provided by a Medicare opt out provider will not be covered. There is no documentation provided showing that there was a signed agreement between you and the provider acknowledging that you were aware that the treating provider was a Medicare opt out provider. You reasonably believed this service would be covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the problem focused limited oral evaluation have been met. Therefore, we decided that the Plan has to pay for the problem focused limited oral evaluation provided on December 22, 2020.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox for the enrollee.
You asked the Plan to pre-approve Botox. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no documentation that the enrollee has tried and failed Dysport or Xeomin.
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 Botox. Our reviewer says that Botox is not medically reasonable and necessary for the enrollee. The Plan requires a trial of Dysport or Xeomin before they will approve the requested drug. In this case, the patient has not tried and failed the required drugs. There is no documentation provided indicating that Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Botox.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a Lithotripsy (50590) provided November 17, 2020.

You asked the Plan to pay for the Lithotripsy. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim did not include a required modifier.

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 50590 is not supported in the medical record. Specifically, the claim did not include a required anatomical modifier to denote if the procedure was performed on the left or right kidney, or if it was bilateral. Based on this information, we decided that Medicare rules for coverage of the Lithotripsy have not been met. Therefore, we decided that the Plan does not have to pay for a Lithotripsy (50590) provided November 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on October 14, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.
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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is limited clinical information provided, but based on these diagnoses and her age, she should be managed for her chronic ischemic heart disease and with risk factor modification per published AHA/ACC guidelines using standard physical exam (blood pressure, etc.) and laboratory studies including a fasting lipid profile. A cardiovascular genetic variant risk panel has very limited application in most situations and has no guidelines or published data to recommend its use, especially in older patients with established heart disease, as it would not provide any clinically relevant information which would change the appropriate medical management of the patient. It is therefore not medically necessary 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 the testing have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on October 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for medical supplies (S1015, S8301) provided October 15, 2020.

You asked the Plan to pay for the items. You say that the items were medically necessary. The Plan denied
your request. The Plan says the CPT codes billed are not eligible for Medicare payment.

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 S1015 & S8301 is not supported in the medical record. Specifically, per the 2020
National Physician Fee Schedule, the CPT codes billed have a status indicator of "I" which means they are not
eligible for Medicare payment. Based on this information, we decided that Medicare rules for coverage of the
items have not been met. Therefore, we decided that the Plan does not have to pay for medical supplies (S1015,
S8301) provided October 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a thyroxine assay (84436) and thyroid testing (84479) provided on December 10, 2020.
You asked the Plan to pay for a thyroxine assay and thyroid testing. You say that these services should be covered. The Plan denied your request. The Plan says these services cannot be separately paid.
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, we have confirmed that codes 84436 and 84479 have a bundled relationship with code 84439 and cannot be paid as billed. These codes cannot be paid as separate line items. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a thyroxine assay (84436) and thyroid testing (84479) provided on December 10, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve use of Rituxan.
You asked the Plan to pre-approve Rituxan. You say that you are appealing this denial. The Plan denied your request. The Plan says that the denial of authorization for IRF care is correct.
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 Rituxan. Our reviewer says that the enrollee meets the Medicare criteria for the requested use of Rituxan. Our physician reviewer found the enrollee has anti-myelin associated glycoprotein (anti-MAG) antibody associated neuropathy and Waldenstrom. The enrollee had 1 previous course of Rituxan without benefit. Waldenstrom is associated with neuropathy. The use of 4 doses of Rituxan is supported by major drug compendia for this condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Rituxan have been met. Therefore, we decided that the Plan has to pre-approve use of Rituxan.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided to the enrollee from June 4, 2020, to July 29, 2020.
You asked the Plan to pay for this claim as billed. You say that this claim was billed correctly. The Plan denied your request. The Plan says Medicare billing criteria were not met. We overturned the Plans denial. The Plan requested a reopen and stated we did not interpret the records correctly.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Sepsis coding and DRG 870 for an enrollee admitted to a long- term acute care hospital. Our Physician Reviewer determined that the documentation supports the billed DRG and sepsis diagnosis. The Plan requested a reopen and stated sepsis was not the principal diagnosis, defined as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. After additional review of the records, our Medical Director has concluded that the Plan is correct in this case. The principal diagnosis is defined as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care." The admission face sheet indicates that the admission diagnosis was J96.90, unspecified respiratory failure. The admission note also indicates that the primary diagnosis at admission was acute respiratory failure. The admission note did not document the presence of sepsis at the time of admission. Therefore, sepsis was not the condition that was chiefly responsible for the admission to the facility and DRG 870 cannot be supported. Therefore, Billing criteria are not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient care provided to the enrollee from June 4, 2020, to July 29, 2020.
Appeal type: Practitioner Services
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 6, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 6, 2020.