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

We decided that the Plan does not have to waive the copayment for the ambulance services provided on
November 27, 2020.

You asked the Plan to waive the copayment for the ambulance services. You say that you feel you should not
be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan
denied your request. The Plan says you received ambulance services on the date of service at issue in this
appeal. The Plan says that the correct copayment has applied per your contract with the Plan.

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 $240
copayment for Ambulance services.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received ambulance
services on November 27, 2020. You have been asked to pay a $240 copayment for the ambulance services.
The ambulance services fall within the Ambulance services 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 the ambulance services provided on November 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental and 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 pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy of the device.

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the TrueMetrix glucose test strips.

You asked the Plan to pre-approve the test strips. You say that this is medically necessary. The Plan denied your request. The Plan says there is no medical reason that you cannot use the formulary brand.

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 test strips. Our reviewer says that the requested test strips are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested product is not a preferred brand. There are no medical records submitted to determine if the requested product is medically necessary or reasonable. 

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 test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve the TrueMetrix glucose test strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) and topical application of fluoride varnish (D1206) provided on November 25, 2020.

You asked the Plan to pay for the bitewing x-rays and the application of fluoride varnish. You say that you tried to refuse the x-rays. You say that you have had pain in your front tooth ever since. You also say that you were advised that dental was covered. The Plan denied your request. The Plan says bitewing x-rays are not listed as covered services. The Plan says that topical application of fluoride varnish 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. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) and topical application of fluoride varnish (D1206) provided on November 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4342) and oral hygiene instructions (D1330) provided on February 1, 2021.

You asked the Plan to pay for the dental services. You say that you specifically told the representative that you needed quality dental coverage when you enrolled. You do not feel you were provided with what you asked for if these services are not covered, and you say that you never received a copy of your Plan's contract or handbook so you could verify what kind of coverage you had.The Plan denied your request. The Plan says these services are not covered by Medicare or by the Plan's mandatory supplemental dental benefit. The Plan offers additional optional benefits, but you did not choose to enroll in additional dental coverage.

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 periodontal scaling and root planing (D4342) and oral hygiene instructions (D1330) provided on February 1, 2021.

Your complaint about possible miscommunication from the Plan during enrollment and missing Plan documents 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 the full amount for the complete upper denture (D5110) and the complete lower denture (D5120) provided on October 22, 2020.

You asked the Plan to pay the full amount for the dental item. You say that you were advised by a plan representative that a full set of dentures was able to be covered. You say that you were given an in network provider. You also say that you have had your previous dentures for 26 years.The Plan denied your request. The Plan says there is an annual maximum benefit of $1,000 for dental services. The Plan also says that the annual maximum benefit has been exhausted.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage and dentures are listed as covered, the annual maximum benefit has been exhausted. The record shows that you had $872 remaining of your annual maximum benefit as of November 11, 2020. The record shows that the Plan paid $815 for the complete upper denture and $57 towards the complete lower denture, for a total of $872.Therefore, we decided that the Plan does not have to pay the full amount for the complete upper denture (D5110) and the complete lower denture (D5120) provided on October 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar sacral orthosis (L0650) provided on September 28, 2020.

You asked the Plan to pay for the lumbar sacral orthosis (L0650). You say that the lumbar sacral orthosis (L0650) provided on September 28, 2020 was medically necessary. The Plan denied your request. The Plan says the services are not covered.

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 lumbar sacral orthosis (L0650). Our reviewer says that the enrollee does not meet criteria for the provided lumbar sacral orthosis. Our physician reviewer found the enrollee's chief complaint was lower back pain.

The available documentation in the case file does not support that the requested lumbar-sacral orthosis (LSO) was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of an appropriate evaluation of the enrollee and insufficient documentation of a credible physical examination of the back.

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 lumbar sacral orthosis (L0650) have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar sacral orthosis (L0650) provided on September 28, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found this enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. Skilled nursing or therapy services are not required on a "daily basis" or as a practical matter on an inpatient basis, in a skilled nursing facility setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic ophthalmic ultrasound (76514) provided on January 14, 2021.

You asked the Plan to waive the copayment for the diagnostic imaging service. You say that you have never had to pay anything other than your office visit copay, and do not feel you should have to pay for the ultrasound. The Plan denied your request. The Plan says the copayment was applied correctly. You have been asked to pay less than the full $50 copayment for this service because the Plan's allowed amount for this service was less than the allowed copayment. The Plan also reviewed your claim history and determined that the reason you have never had to pay a copayment for this ultrasound is that the provider has not billed for this diagnostic exam before.

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 $50 copayment for outpatient diagnostic tests provided by a specialty physician.

You have been asked to pay a $11.72 copayment for the diagnostic imaging service provided by an ophthalmologist. A diagnostic ophthalmic ultrasound falls within the outpatient diagnostic tests benefit category and was provided by a specialty physician in this case. 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 the diagnostic ophthalmic ultrasound (76514) provided on January 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sanexas neoGen-Series Therapy (electrical cell stimulation) and the associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend provided on August 11, 2020.

You asked the Plan to pay for the Sanexas neoGen-Series Therapy (electrical cell stimulation) and the associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend. You say that the Sanexas neoGen-Series Therapy (electrical cell stimulation) and the associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend was medically necessary. The Plan denied your request. The Plan says the Sanexas neoGen-Series Therapy (electrical cell stimulation) and the associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend was not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the Sanexas neoGen-Series Therapy (electrical cell stimulation) and the associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend. Our reviewer says that the Sanexas neoGen-Series Therapy (electrical cell stimulation) and the associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend was not medically necessary. Our physician reviewer found the member underwent treatment/therapy with a Sanexas neoGen-Series Therapy (electrical cell stimulation) for their history of low back pain. This specific device/technology has not yet been evaluated in any prospective clinical trials for use in the management of low back pain (or other similar forms of neuropathic pain). Likewise, there are no professional society guidelines readily available that otherwise support the use of this technology in the management of low back pain. The technology that was utilized on the date(s) of service under review in this case was not consistent with that supported by the generally accepted standards of practice/care. Rather, given the need for further study of the technology of this device would have otherwise been better classified as being investigational/experimental in nature. For these reasons, the services provided would not have met the SSA/Medicare definition of medical necessity. 

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 Therapy (electrical cell stimulation) and the associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend have not been met. Therefore, we decided that the Plan does not have to pay for the Sanexas neoGen-Series Therapy (electrical cell stimulation) and the associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend provided on August 11, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on September 29, 2020.

You asked the Plan to pay for the subsequent nursing facility care. You say that the services provided were medically necessary and meet all applicable professionally recognized standards of healthcare.The Plan denied your request. The Plan says the enrollee was covered under the hospice benefit on this date of service.

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 dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on September 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sanexas neoGen-Series Therapy (electrical cell stimulation) and the associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend provided on August 13, 2020.

You asked the Plan to pay for the Sanexas neoGen-Series Therapy (electrical cell stimulation) and the associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend. You say that the Sanexas neoGen-Series Therapy (electrical cell stimulation) and the associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend was medically necessary. The Plan denied your request. The Plan says the Sanexas neoGen-Series Therapy (electrical cell stimulation) and the associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend was not medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the Sanexas neoGen-Series Therapy (electrical cell stimulation) and the associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend. Our reviewer says that the Sanexas neoGen-Series Therapy (electrical cell stimulation) and the associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend was not medically necessary. Our physician reviewer found the services furnished to the member involving the Sanexas neoGen-Series Therapy (electrical cell stimulation) have not been validated for use in low back pain (or any form of neuropathic pain). The literature on this specific service/therapy is largely limited to studies done by the device's manufacturer. There have not been a sufficient number of well-designed controlled studies done in order to permit conclusions that this therapy is safe and effective for use. The use of this technology would otherwise not be consistent with the generally accepted standards of practice and/or care. Given these factors this service would not meet the Medicare/SSA definition of medical necessity. 

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 Therapy (electrical cell stimulation) and the associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend have not been met. Therefore, we decided that the Plan does not have to pay for the Sanexas neoGen-Series Therapy (electrical cell stimulation) and the associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend provided on August 13, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from September 12, 2020, to October 11, 2020.

You asked the Plan to pay for the SNF services. You say that the services are coverable under the Medicare Act.The Plan denied your request. The Plan says the enrollee required no nursing services which would be considered skilled services by Medicare.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.

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 SNF services have not been met.Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from September 12, 2020, to October 11, 2020.