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

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), and the panoramic x-ray (D0330) provided on March 11, 2020.

You asked the Plan to pay for the dental services. You say that you did not go to this dentist for x-rays. You say that you wanted to have a tooth pulled. You say that you told them you are on limited income and could not afford to pay anything that insurance did not cover. You also say that you do not have money to pay this bill. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan says that 1 panoramic x-ray is covered every 3 plan years. The Plan also says that the frequency limits have been exceeded.

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 the services are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation and a panoramic x-ray that you received on June 9, 2017. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), and the panoramic x-ray (D0330) provided on March 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on January 21, 2021 by an out of network (OON) provider.

You asked the Plan to pay for lab tests. You say that you should not be responsible for this claim. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and this testing was also ordered by an out-of-network provider.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on January 21, 2021 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Natalizumab infusion (J2323) received on January 4, 2021.

You asked the Plan to waive the coinsurance for a Natalizumab infusion. You say that the coinsurance is very untenable for your fixed income and could result in your discontinuation of a medicine that has kept you from drastic health care decline. The Plan denied your request. The Plan says the correct coinsurance was applied.

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 17% coinsurance for Medicare Part B covered drugs. 

You have been asked to pay $756.57, or 17% of the Medicare-allowed charge of $4,450.39, for a Natalizumab infusion. A Natalizumab infusion 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 a Natalizumab infusion (J2323) received on January 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).

You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested procedure is experimental/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 a Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the requested procedure is considered experimental/investigational at this time. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on March 4, 2021.

You asked the Plan to pay for the office visit. You say that the patient was referred by their primary care physician and the claim should be reimbursed. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the service was not approved in advance.

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 the office visit provided by an out-of-network provider on March 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure.

You asked the Plan to pre-approve an Intracept procedure. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested procedure is experimental/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 an Intracept procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the requested procedure is considered an experimental/investigational procedure. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

You asked the Plan to pre-approve Prolia. You say that this is necessary because the enrollee has osteopenia with a high risk of fractures. The Plan denied your request. The Plan says this use is not supported.

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 Prolia. Our reviewer says that the requested use of Prolia is not supported in this case. Our physician reviewer found Prolia is not an accepted treatment for low bone mineral density (BMD) in primary hyperparathyrodism. In addition, studies using it to treat hyperparathyrodism did not show improvement in forearm BMD. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by a
participating provider on January 6, 2021.

You asked the Plan to waive the copayment for specialist services. You say that you do not agree with
copayment. The Plan denied your request. The Plan says the correct copayment has been applied.

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 physician/practitioner services/specialist.

You have been asked to pay a $40 copayment for specialist services. The physician that provided these services
is considered a specialist; therefore, the correct copayment has been applied. Specialist services fall within the
physician/practitioner services/specialist 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 specialist services provided by a participating provider on January 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on December 23, 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 procedure code 15275 is not supported.

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 15275 is application of skin substitute graft to face, scalp,
eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to
100 sq cm; first 25 sq cm or less wound surface area.

We find that CPT code 15275 is not supported in the medical record. Specifically, there is no documentation of
an application of skin substitute graft to the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet,
and/or multiple digits for a total area up to 100sq centimeters. 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 surgical services rendered on December 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on March 10, 2021.

You asked the Plan to pay for the problem focused limited oral evaluation. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service 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, 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 problem focused limited oral evaluation provided on March 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for chimeric antigen receptor (CAR) T-cell therapy (0537T) provided on November 13, 2020.

You asked the Plan to pay for CAR T-cell therapy. You say that you are requesting payment for this service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because Original Medicare is responsible for coverage of this service.

The Plan must follow Medicare rules. Medicare rules say that for dates of service in calendar year 2020, original fee-for service Medicare will pay for covered CAR T-cell therapy because it has been determined to be a significant cost. 

We looked at the file and Medicare rules. For this date of service, the Plan is not responsible for payment of CAR T-cell therapy. Payment should instead be requested from Original Medicare. Therefore, we decided that the Plan does not have to pay for chimeric antigen receptor (CAR) T-cell therapy (0537T) provided on November 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound care provided from January 13, 2021, to January 29, 2021.
You asked the Plan to waive the copayment for the wound care services. You say that you should not have a $170 copayment for the specialist to clean and bandage your foot. The Plan denied your request. The Plan says the allowed amounts on the claims for the wound debridement services were less than your copayment so you were charged the lesser amount correctly. You have no liability on the claims in February, so the dates were not accepted as part of the appeal.
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 $325 copayment for Outpatient Surgery. You have been asked to pay less than the required $325 copayment for the wound care services because the Medicare allowed amount was less. The wound care services fall within the Outpatient Surgery benefit category. The submitted code 16020 is considered a surgical procedure by Medicare. 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 wound care provided from January 13, 2021, to January 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray rendered on April 13, 2021.

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 the services are not separately payable.

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.

The provider submitted a claim for procedure codes 71045 (chest x-ray, single view) and 71046 (chest x-ray, two views). Code 71045 is a column II code with a modifier indicator of 1 when billed with column I code 71046. Code 71045 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the chest x-ray rendered on April 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the MI profile testing provided on November 2, 2020.

You asked the Plan to pay for the testing services. You say that the physician ordered molecular testing as part of the enrollee's treatment plan. The Plan denied your request. The Plan says the test does not meet Medicare criteria.

The Plan must follow Medicare rules. Medicare rules say next generation sequencing is only covered under certain medical indications.

We looked at the file and the rules. The test at issue has not had a technical assessment completed satisfactorily by MolDX. There is no indication this testing is a covered service by Medicare or the Plan. 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 MI profile testing provided on November 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869).

You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested procedure is experimental/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 a Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Vertiflex 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 a Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) provided on February 25, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the domiciliary or rest home visit. You say that your physician provided medically necessary services to the enrollee in good faith. In consideration for the services rendered, your doctor is seeking reimbursement from the office. 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 domiciliary or rest home visit (99336) provided on February 25, 2021 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that all of the enrollee's providers, including the physical therapist, occupational therapist, and hospital doctors agree that the enrollee needs to go to an acute rehab facility. You also say that it would be a hardship for the enrollee to attend outpatient physical and occupational therapy. The Plan denied your request. The Plan says the enrollee is overqualified for inpatient rehabilitation.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

Our reviewer found that the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. Our physician reviewer also found that there is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the acute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for mesh removal (11008-59), mesh implantation (49568-59), and a non-tunneled centrally inserted central venous catheter insertion (36556-59) provided on July 20, 2020.

You asked the Plan to pay for mesh removal, mesh implantation, and a non-tunneled centrally inserted central venous catheter insertion. You say that these services were billed correctly. The Plan denied your request. The Plan says these codes are not documented.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We 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 mesh removal, mesh implantation, and a non-tunneled centrally inserted central venous catheter insertion. Our reviewer says that these codes are not supported. Our physician reviewer found the operative report did not include enough documentation to confirm prosthetic material or mesh was removed for infection to support 11008. It also did not document implantation of mesh or other prosthesis, therefore 49568 cannot be verified. For 36556, the operative report did not document an insertion of a non-tunneled catheter. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of mesh removal, mesh implantation, and a non-tunneled centrally inserted central venous catheter insertion have not been met. Therefore, we decided that the Plan does not have to pay for mesh removal (11008-59), mesh implantation (49568-59), and a non-tunneled centrally inserted central venous catheter insertion (36556-59) provided on July 20, 2020.