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

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on January 13, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that you did not receive treatment. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
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 Medicare-covered specialist visit. You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record shows the follow-up visit was to review recent diagnostic tests and your treatment options were discussed, including facet injections. 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 specialist office visit provided on January 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the closed treatment of a fracture provided on December 23, 2020.
You asked the Plan to waive the coinsurance for the closed treatment of a fracture. You say that you disagree with the charges because you feel the service you received should not be considered a surgical procedure. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 50% coinsurance for out-of-network physician/practitioner services, including doctor's office visits. You received the closed treatment of a fracture from an out-of-network provider, on December 23, 2020. Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. You have been asked to pay $221.35, which is less than the 50% coinsurance for the closed treatment of a fracture. The closed treatment of a fracture 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 coinsurance for the closed treatment of a fracture provided on December 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the comprehensive oral evaluation
(D0150) and panoramic radiographic image (D0330) provided August 3, 2020, and the surgical extraction of
erupted tooth (D7210) provided August 19, 2020.

You asked the Plan to provide additional payment for the oral exam, x-ray and tooth extraction. You say that
you needed dental services corrected and were told you could go to any provider. The Plan denied your request.

The Plan says an exception for out-of-network (OON) coverage has been made as a result of the COVID-19
waiver and reimbursement of the contracted rate has been issued.

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 oral exam,
x-ray and tooth extraction when they are provided by a provider in the Plan's dental vendor network.

We looked at the file and Medicare rules. In this case the enrollee obtained services from an OON provider.
The Plan has made an exception to the vendor network policy and provided coverage for the services and is
providing coverage to the OON services based on the CMS COVID-19 waiver allowing the Plan flexibilities to
modify requirements. The Plan provided reimbursement of the maximum contracted rate for the services. The
non-contract provider may bill for the difference between the Plan's contracted rate and the total amount billed.
Based on this information, we decided that the Plan does not have to provide additional payment for the
comprehensive oral evaluation (D0150) and panoramic radiographic image (D0330) provided August 3, 2020,
and the surgical extraction of erupted tooth (D7210) provided August 19, 2020.

Your complaint about receiving poor service from a network provider and potential miscommunication from
the Plan about coverage of the services 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy.
You asked the Plan to pre-approve physical therapy. 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 medically necessary outpatient therapy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee has had prior therapy for this condition and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. The enrollee has been instructed in and is compliant in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve physical therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided October 13, 2020.

You asked the Plan to pay for the lumbar-sacral orthosis. You say that the item provided was medically necessary. The Plan denied your request. The Plan says this patient did not receive video or telephonic visit by the ordering physician in order to warrant the codes billed.

The Plan must follow Medicare rules. Medicare rules say that the spinal orthosis is subject to the criteria listed in the Medicare rules section. 

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. Our reviewer says that the requested item was not medically necessary and reasonable. Our physician reviewer found that an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis 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 have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided October 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (88184, 88189, 88185, 85060) provided on November 18, 2020 by an out of network (OON) provider.
You asked the Plan to pay for OON laboratory services. You say that this was medically necessary. 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 (88184, 88189, 88185, 85060) provided on November 18, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for injection of hyaluronan (a Medicare Part B drug) provided from November 17, 2020, to November 19, 2020.
You asked the Plan to waive the coinsurance for Part B drugs. You say that you should not have to pay this bill because you have had these services covered in past years. The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Part B drugs. The allowed amount of these drugs is $369.41, resulting in a coinsurance obligation of $73.88. You have been asked to pay 20% coinsurance for Part B drugs. Part B drugs falls within the Medicare Part B Prescription Drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for injection of hyaluronan (a Medicare Part B drug) provided from November 17, 2020, to November 19, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve aquatic therapy with therapeutic exercises.
You asked the Plan to pre-approve aquatic therapy with therapeutic exercises. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 aquatic therapy with therapeutic exercises. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal inability to tolerate a land-based therapy program or inability to complete a home exercise program. You are ambulating a distance that does not require ongoing supervised physical therapy and your deficits can be met with a home exercise program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of aquatic therapy with therapeutic exercises have not been met. Therefore, we decided that the Plan does not have to pre-approve aquatic therapy with therapeutic exercises.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory test provided by an out-of-network provider on November 15, 2019.

You asked the Plan to pay for the laboratory test. You say that you are appealing the claim with medical records for further processing. The Plan denied your request. The Plan says in-network providers were available to perform the services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 laboratory test provided by an out-of-network provider on November 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided November 11, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that the item provided was medically necessary. The Plan denied your request. The Plan says this service was provided as a result of an unsolicited phone call.
The Plan follows Medicare rules. Medicare rules say that a spinal orthosis is subject to the criteria listed in the Medicare rules section. 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. Our reviewer says that the requested item was not medically reasonable and necessary. Our physician reviewer found the physician writes that the enrollee has core muscle weakness and would benefit from a back brace to help alleviate back pain as a result of core muscle weakness. The clinical documentation in the case file does not support this claim. The documentation does not support that the requested lumbar-sacral orthosis was
medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. 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 have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided November 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant for tooth #3 provided on November 30, 2020.

You asked the Plan to pay for the endosteal implant. You say that you feel this service should be covered. The Plan denied your request. The Plan says this service is not a benefit for tooth #3.

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, surgical placement of an implant body is to replace a single missing natural anterior (front) tooth only. Implant services for posterior (back) teeth are not a covered benefit. Tooth #3 is a posterior (back) tooth and does not qualify for implant benefits. Therefore, we decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant for tooth #3 provided on November 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series x-ray (D0210) provided on November 30, 2020.
You asked the Plan to pay for the dental services. You say that this provider is clearly listed as in network on the Plan's website. The Plan denied your request. The Plan says the provider in this case is not in the Plan's network. The Plan also says that dental services that you receive out of network 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, dental services that you receive out of network are not covered. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series x-ray (D0210) provided on November 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ConfirmMDx testing provided on November 12, 2020.
You asked the Plan to pay for the testing services. You say that the testing is a covered benefit. The Plan denied your request. The Plan says coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx is only covered under certain medical indications.
We looked at the file and Medicare rules. The medical records provided show that the enrollee is being managed by active surveillance. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the ConfirmMDx testing provided on November 12, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the trigger point injections provided from November 23, 2020, to December 20, 2020.
You asked the Plan to waive the copayments for the trigger point injections. You say that these are injections into the muscle to relieve debilitating pain. You say the injections are not surgery. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
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 $350 copayment for Medicare-covered surgery services at an in-network hospital outpatient facility. You have been asked to pay a $272.98 copayment, which is less than the standard amount, for the trigger point injections on each date of service. ($272.98 x 4 = $1,091.92). The trigger point injections fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the trigger point injections are considered a surgical procedure. 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 trigger point injections provided from November 23, 2020, to December 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pulp vitality tests (D0460) provided on November 11, 2020.

You asked the Plan to pay for the pulp vitality tests. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service is not covered under your 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 pulp vitality tests (D0460) provided on November 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular testing provided on December 19, 2019.
You asked the Plan to pay for the testing services. You say that the services predict the response to treatment and improve clinical outcomes. The Plan denied your request. The Plan says the service is not a Medicare covered service.
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. Chemosensitivity profile tumor panels are not a Medicare covered service. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the molecular testing provided on December 19, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Kadclya (ado-trastuzumab emtansine) (J9354) and Fulvestrant (J9395).
You asked the Plan to pre-approve Kadclya (ado-trastuzumab emtansine) (J9354) and Fulvestrant (J9395). You say that the enrollee needs to start this treatment as soon as possible. The Plan denied your request. The Plan says that the requested therapy is considered experimental/investigational and not supported by compendia or peer scientific literature.
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 Kadclya (ado-trastuzumab emtansine) (J9354) and Fulvestrant (J9395). Our reviewer says that the drugs are reasonable and medically necessary. Our physician reviewer found combination therapy for both HER2+ and ER+ cancers is standard. The use is supported by the major drug compendia NCCN Guidelines Version 4.2021 Invasive Breast Cancer. The documentation supports that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 Kadclya (ado-trastuzumab emtansine) (J9354) and Fulvestrant (J9395) have been met. Therefore, we decided that the Plan has to pre-approve Kadclya (ado-trastuzumab emtansine) (J9354) and Fulvestrant (J9395).
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.