Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on August 9, 2020.
You asked the Plan to pay for the office visit. You say that you thought you had until year-end to file the claim. The Plan denied your request. The Plan says the request was received past the 60-day timeframe.
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 submit your claim within 60 days. We looked at the file and the rules. The claim for reimbursement was not received until November 5, 2020. This is more than 60 days past the date of service. Therefore, we decided that the Plan does not have to pay for the office visit provided on August 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial mandibular overdenture (dental code D5866).
You asked the Plan to pre-approve dental service. You say that you are having severe pain and trouble eating.
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this
dental service is not covered by the Plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a
partial mandibular overdenture (dental code D5866).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion services provided on October 15, 2020 billed with codes 99601 and 99602.
You asked the Plan to pay for the home infusion services. You say that this should be paid due to medical necessity. The Plan denied your request. The Plan says this is not billed with valid codes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. CPT codes 99601 and 99602 have a status indicator of "I" on the Physician Fee Schedule. This means that they are invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion services provided on October 15, 2020 billed with codes 99601 and 99602.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the pharmacy dispenses
this drug to the enrollee to self-administer, or to take it to the provider. The Plan also says that this medication
has been approved under the enrollee's Part D benefit.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B,
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be
brought to the office for administration. Since the medication does not represent an expense to the physician
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that
the Plan does not have to pre-approve Prolia (J0897).
Benefits for Prolia 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CxBladder Monitor testing (procedure code 0013M) provided on October 8, 2020.
You asked the Plan to pay for genetic testing. You say that this testing is eligible for payment as long as the service meets medical necessity guidelines. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this test is not covered.
The Plan must follow Medicare rules. Medicare rules say that genetic testing code 0013M is not covered for date of service October 8, 2020. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for CxBladder Monitor testing (procedure code 0013M) provided on October 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the transcatheter aortic valve replacement services coded 33361 provided on September 2, 2020.

You asked the Plan to pay for the transcatheter aortic valve replacement services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation is missing required information.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code 33361 is transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach.

We find that CPT code 33361 is not supported in the medical record. Specifically, these services were billed without the appropriate clinical trial information. The clinical trial number was not billed on the claim. Based on this information, we decided that Medicare rules for coverage of the transcatheter aortic valve replacement services have not been met. Therefore, we decided that the Plan does not have to pay for the transcatheter aortic valve replacement services coded 33361 provided on September 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital visit (G0463) wound debridement (11042) provided on February 4, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the outpatient visit. You say that you disagree with this decision and request reconsideration of the denial. Based on the enrollee's symptoms and previous history, the services provided were not only appropriate but were in fact medically necessary. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 outpatient hospital visit (G0463) wound debridement (11042) provided on February 4, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to adjust the coinsurance for the cataract surgeries provided on November 9, 2020 and November 23, 2020.
You asked the Plan to adjust the coinsurance for the cataract surgeries. You say that the patient cannot choose where the Dr does the surgery. The Plan denied your request. The Plan says you were charged this coinsurance 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 40% coinsurance for out-of-network Outpatient Surgery. You have been asked to pay 40% coinsurance for the cataract surgeries. The cataract surgeries fall within the out-of-network Outpatient Surgery 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 adjust the coinsurance for the cataract surgeries provided on November 9, 2020 and November 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for hospital outpatient clinic visit (G0463)
provided November 16, 2020.

You asked the Plan to waive the copayment for the hospital outpatient clinic visit. You say that you were told
by the provider's billing department that the $132.80 charge was for the use of their facility. You are disputing
this charge. The office you went to wasn't in the hospital. It was an office complex separate from the hospital.
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 $$350
copayment for each covered non-surgical visit in an outpatient clinic after you meet your $250 deductible.

You have been asked to pay $132.80 for the hospital outpatient clinic visit. Since the Medicare allowable
amount is less than the copayment amount, you are only responsible for the lesser amount. Page 58 of the EOC
also says that when you visit a provider, you may be charged an additional fee. This fee reflects a trend in
hospitals buying doctors practices and adding additional fees to patient bills. In those cases, the outpatient cost
share applies to these services. The hospital outpatient clinic visit falls within the Outpatient hospital 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 hospital outpatient clinic visit
(G0463) provided November 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator, electronic shock unit (E0745)
provided September 16, 2020.
You asked the Plan to pay for the neuromuscular stimulator. You say that the claim was denied for missing or
invalid modifier. However, you got payment on other patients for code E0745 with the same modifiers to
which the rep suggested to send an appeal with all supporting medical records. The Plan denied your request.
The Plan says there is no evidence of an established relationship between the enrollee and the ordering
physician.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. The Plan has attested that this enrollee was contacted via an
unsolicited phone call regarding provision of the item at issue. Based on this information, we decided that
Medicare rules for coverage of the neuromuscular stimulator have not been met. Therefore, we decided that the
Plan does not have to pay for the neuromuscular stimulator, electronic shock unit (E0745) provided September
16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Qutenza.

You asked the Plan to pre-approve Qutenza. The Plan denied your request. The Plan says this 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 Qutenza. Our reviewer says that Qutenza is not medically reasonable and necessary in this case. Our physician reviewer found that this would an off-label use for this medication. There are no papers supporting its use in demyelinating neuropathy. The request is not medically reasonable or necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Qutenza have not been met. Therefore, we decided that the Plan does not have to pre-approve Qutenza.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID-19 test you received on December 14, 2020.
You asked the Plan to pay for the COVID-19 test. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, the COVID-19 test, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the COVID-19 test you received on December 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided from September 9, 2020 to November 9, 2020 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that these services were medically necessary, and you need reimbursement. The Plan denied your request. The Plan says out-of-network dental care is 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, items and services received out-of-network are not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services provided from September 9, 2020 to November 9, 2020 by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 cone beam CT capture and interpretations (D0364 x2),
13 guided tissue regenerations (D4266 x13), 12 surgical placements of implant bodies: endosteal implants
(D6010 x12), 2 sinus augmentations with bone or bone substitutes (D7951 x2), 12 bone replacement grafts for
ridge preservations (D7953 x12).

You asked the Plan to pre-approve the cone beam CT capture and interpretations, guided tissue regenerations,
endosteal implants, sinus augmentations with bone or bone substitutes, and bone replacement grafts. You say
that you would like to appeal these services. The Plan denied your request. The Plan says these services 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 pre-approve 2
cone beam CT capture and interpretations (D0364 x2), 13 guided tissue regenerations (D4266 x13), 12 surgical
placements of implant bodies: endosteal implants (D6010 x12), 2 sinus augmentations with bone or bone
substitutes (D7951 x2), 12 bone replacement grafts for ridge preservations (D7953 x12).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for enteral feeding supplies (B4035, B4150, B9002) provided
from November 8, 2019, to November 25, 2019.

You asked the Plan to pay for enteral feeding supplies. You say that these items should be covered because the
enrollee was a private pay resident. The Plan denied your request. The Plan says these items were billed with
place of service 31, skilled nursing facility, and are not covered for use in a skilled nursing facility.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.

Records show that enteral feeding supplies was used in a SNF or hospital. Therefore, we decided that the Plan
does not have to pay for enteral feeding supplies (B4035, B4150, B9002) provided from November 8, 2019, to
November 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the electronic neuromuscular stimulator provided on June 16,
2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says there is no
evidence of an established relationship between the enrollee and the ordering physician.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the medical record
contains sufficient documentation of the enrollee's medical condition to substantiate the necessity for the type
and quantity of items ordered.
The record does not contain sufficient medical records which support medical necessity for the supplies
provided in this case. 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 the electronic
neuromuscular stimulator provided on June 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on December 7, 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 you by an out-of-network provider on December 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapeutic parenteral drugs, 3 units of intravenous moderate sedation, 3 root canals, 3 retainer crowns, a pontic, 2 porcelain crowns, 2 prefabricated post and core in addition to a crown, 2 removal of residual tooth roots, scaling and root planing for all 4 quadrants, and 7 fillings.
You asked the Plan to pre-approve the dental services. You say that your cardiologist wants you to have this work done for health reasons. You say that every time you need a procedure done, your cardiologist is concerned about your health. You say that you need these services to be covered. The Plan denied your request. The Plan says there is combined $1,000 coverage limit per plan year for preventive and comprehensive dental services. The Plan also says that the coverage limit has been reached.
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, there is a coverage limit of $1,000 which has been reached. The record shows that the Plan has already approved the following services that were requested and reach the total coverage limit.
Service           Estimated Payment
D0220                      $20
D0230                      $18
D6740 (# 3)             $400
D6245 (# 4)           $352.50
D7250 (# 4)             $181
D2954 (# 5)            $28.50
TOTAL:                  $1,000
Therefore, we decided that the Plan does not have to pre-approve therapeutic parenteral drugs, 3 units of intravenous moderate sedation, 3 root canals, 3 retainer crowns, a pontic, 2 porcelain crowns, 2 prefabricated post and core in addition to a crown, 2 removal of residual tooth roots, scaling and root planing for all 4 quadrants, and 7 fillings.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had from January 13, 2021, to February 24, 2021.
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible for the cost share.
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 $40 copayment for each specialist office visit or telehealth visit. Review of the file shows that you received specialist services from January 13, 2021, to February 24, 2021. You have been asked to pay a $40 copayment for each visit. The services fall within the physician 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 office visit you had from January 13, 2021, to February 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for radiofrequency ablation to the SI (sacroiliac joint) (64625) provided November 16, 2020.

You asked the Plan to pay for radiofrequency ablation. You say that CPT 64625 needs to be sent back for reconsideration. The Plan denied your request. The Plan says the use of radiofrequency ablation for pain management related to sacroiliac joint pain has not been shown to provide a clear long-term benefit over standard treatment for chronic sacroiliac joint pain.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pay for radiofrequency ablation to the SI (sacroiliac joint) (64625) provided November 16, 2020.