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

We decided that the Plan does not have to pre-approve Ziextenzo.
You asked the Plan to pre-approve Ziextenzo. You say that the requested Ziextenzo is medically necessary. The Plan denied your request. The Plan says the requested Ziextenzo is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Ziextenzo. Our reviewer says that the requested Ziextenzo is not medically necessary. Our physician reviewer found the enrollee is with a past medical history of thrombocytopenia, anemia, pancytopenia, chronic kidney disease stage 3, neutropenia, diabetes mellitus 2, hypertension, and splenomegaly. The enrollee is not on chemotherapy. Ziextenzio is only necessary after myelosuppressive chemotherapy has been given. The requested Ziextenzio is not medically necessary 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 Ziextenzo have not been met. Therefore, we decided that the Plan does not have to pre-approve Ziextenzo.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services and diagnostic services provided on December 1, 2020, to December 15, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services and diagnostic services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 and diagnostic services provided on December 1, 2020, to December 15, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the Star targeted next generation sequencing panel testing provided on
September 21, 2020.
You asked the Plan to pay for the testing services. You say that the documentation supports the medical
necessity of the services provided. The Plan denied your request. The Plan says that the panel does not
represent specific pathogens that cause a common syndrome.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
We looked at the file and the rules. The Local Coverage Determination and Article (L37764 and A57579) the
plan used are not binding in this case. The rules do not have jurisdiction where the services were provided.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Therefore, we decided that the Plan has to pay for the Star targeted next
generation sequencing panel testing provided on September 21, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided by an out-of-network provider on
August 28, 2020.

You asked the Plan to pay for the psychotherapy. You say that the service was provided with no adequate time
to obtain authorization. You say that the records reflect the medical necessity of the service and the claim
should be processed for payment. The Plan denied your request. The Plan says authorization for out of network
services was not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for psychotherapy provided by an out-of-network
provider on August 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an x-ray (71046), echocardiography (93312), and two cardioversion procedures (92960) provided from October 20, 2020, to December 22, 2020.
You asked the Plan to waive the copayments for an x-ray, echocardiography, and two cardioversion procedures. You say that you should be charged less because of the Plan's motto. The Plan denied your request. The Plan says these services processed correctly. 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 $25 copayment for each x-ray service, a $160 copayment for each Medicare-covered radiological diagnostic service, and a $370 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital. You have been asked to pay a $25 copayment for an x-ray, a $160 copayment for echocardiography, and a $370 copayment for each of two cardioversion procedures. 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 copayments for an x-ray (71046), echocardiography (93312), and two cardioversion procedures (92960) provided from October 20, 2020, to December 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator rendered on October 4, 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 there is no valid proof of delivery.

The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery. 

We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator rendered on October 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthotics (E0745) provided October 1, 2020.
You asked the Plan to pay for orthotics. You say that the orthotics were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.
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 record does not contain a valid proof of delivery. No itemized shipping documentation was provided. 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 orthotics (E0745) provided October 1, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the detection test by nucleic acid for Mycoplasma pneumoniae, COVID-19 test, detection test by nucleic acid for Staphylococcus aureus, and detection test by nucleic acid for organism provided on June 23, 2020.
You asked the Plan to pay for the detection test by nucleic acid for Mycoplasma pneumoniae, COVID-19 test, detection test by nucleic acid for Staphylococcus aureus, and detection test by nucleic acid for organism. You say that you have no knowledge of the enrollee's coverage prior to the specimen's arrival at the laboratory. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
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 detection test by nucleic acid for Mycoplasma pneumoniae, COVID-19 test, detection test by nucleic acid for Staphylococcus aureus, and detection test by nucleic acid for organism provided on June 23, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the interim partial denture (including retentive/clasping materials, rests, and teeth), maxillary (D5820) received January 13, 2021.
You asked the Plan to pay for the interim partial denture (D5820). You say that your dental coverage covers 50% of partial plates. The Plan denied your request. The Plan says your benefit includes specific covered codes. The service you received (D5820) is not one of the covered codes.
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 interim partial denture (including retentive/clasping materials, rests, and teeth), maxillary (D5820) received January 13, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for needle insertion(s) without injection(s); 3 or more muscles (CPT Code 20561) and physical therapy services (CPT Code 97140) provided on June 24, 2020.
You asked the Plan to waive the copayment for the services. You say that you believe you should be charged for one copayment only per visit. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that on May 6, 2020, you had needle insertion(s) without injection(s); 3 or more muscles (CPT Code 20561) with a specialist/practitioner with a $35 copayment. Also, physical therapy services (CPT Code 97140) with a copayment of $35 which total $70 for the services received. 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 needle insertion(s) without injection(s); 3 or more muscles (CPT Code 20561) and physical therapy services (CPT Code 97140) provided on June 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a telehealth office visit (99214) provided on January 22, 2021.

You asked the Plan to pay for a telehealth office visit. You say that this was billed correctly. The Plan denied your request. The Plan says this was billed with an incorrect POS.

The Plan must follow Medicare rules. Medicare rules say that providers should submit telehealth services claims, using Place of Service (POS) 02 - Telehealth, to indicate they furnished the billed service as a professional telehealth service from a distant site.

We looked at the file and Medicare rules. The services at issue were telehealth services that were not billed
with POS 02. Based on this information, we decided that Medicare rules for coverage of a telehealth office visit have not been met. Therefore, we decided that the Plan does not have to pay for a telehealth office visit (99214) provided on January 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from November 21, 2020, to November 23, 2020.
You asked the Plan to pay for the self-administered drugs. You say that these drugs should be covered. The Plan denied your request. The Plan says self-administered drugs are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided from November 21, 2020, to November 23, 2020.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on November 16, 2020.
You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed as billed.
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 HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg. We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using
standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met. Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on November 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on February 4, 2021 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that your lab performed all the tests that were ordered by the referring physician. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 lab work provided on February 4, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient office visit (99203) provided March 11, 2021.
You asked the Plan to waive the copayment for the office visit. You say that you feel that if you are going to pay the specialist copay, then you should be able to see the specialist that you had the appointment with not the PA or anyone else. The Plan denied your request. The Plan says the claim was processed and the correct copayment was applied per the Evidence of Coverage.
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 $40 copayment for each in person specialist visit for Physician/Practitioner services, including doctor's office visits. You have been asked to pay $40 copayment for each in person specialist visit for the office visit. the office visit falls within the Physician/Practitioner services, including doctor's office visits 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 outpatient office visit (99203) provided March 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on October 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you needed services that the Plan provider failed to provide. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
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 the office visit provided on October 13, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and mandibular partial denture (D5214).
You asked the Plan to pre-approve the maxillary and mandibular partial dentures. You say that you would like these dentures to be approved for coverage. The Plan denied your request. The Plan says you do not have any upper teeth to hold an upper partial. The Plan also says that you have too many remaining lower teeth and no room to receive a lower partial.
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 the maxillary and mandibular partial dentures when the services are medically necessary and reasonable.
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 maxillary and mandibular partial dentures. Our reviewer says that a maxillary partial denture (D5213) and mandibular partial denture (D5214) are not medically reasonable and necessary. Our physician reviewer found the dental record and radiographs indicate the absence of all maxillary teeth. The treatment plan should have been for a complete maxillary denture. Our reviewer found that two mandibular teeth appear to be missing but there is no need to replace them with a partial denture since the remaining teeth have drifted, closing the spaces. Our physician reviewer also found that a complete maxillary denture would provide adequate masticatory function. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the maxillary and mandibular partial dentures have not been met. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and mandibular partial denture (D5214).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (80053, 80061, 83036, 84443, 84550, 85025, P9604, 82746, 82607, 36415) provided on January 19, 2021 by an out of network (OON) provider.
You asked the Plan to pay for OON laboratory services. You say that this should be covered. The Plan denied your request. The Plan says this was 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 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 laboratory services (80053, 80061, 83036, 84443, 84550, 85025, P9604, 82746, 82607, 36415) provided on January 19, 2021 by an out of network (OON) provider.