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

We decided that the Plan does not have to pay for three dental implants (D6010), three implant posts (D6057), two implant bridges (D6071), a bridge (D6241), three facial surgeries (D7953), and an implant crown (D6061) provided by an out-of-network provider.
You asked the Plan to pay for dental implants, implant posts, implant bridges, a bridge, facial surgeries, an implant crown. You say that you would like approval for these services. The Plan denied your request. The Plan says the dental services requested are not a Medicare covered benefit.
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 dental implants, implant posts, implant bridges, a bridge, facial surgeries, an implant crown. when the services are medically necessary and reasonable. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of dental implants, implant posts, implant bridges, a bridge, facial surgeries, an implant crown. have not been met. Therefore, we decided that the Plan does not have to pay for three dental implants (D6010), three implant posts (D6057), two implant bridges (D6071), a bridge (D6241), three facial surgeries (D7953), and an implant crown (D6061) provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the correct cost sharing amount has been applied to prophylaxis (D1110), a periodic oral evaluation (D0120), bitewings (D0274), and fluoride varnish (D1206) provided by a non-participating provider on June 24, 2021.

You asked the Plan to pay for prophylaxis, a periodic oral evaluation, bitewings, and fluoride varnish. You say that these services were preventative and should be fully covered. The Plan denied your request. The Plan says the correct cost sharing amount has been applied. The Plan says these charges are a contractual obligation with the Plan and cannot be waived.

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 prophylaxis, a periodic oral evaluation, bitewings, and fluoride varnish by an out-of-network provider.

We looked at the file and Medicare rules. For services obtained out-of-network the Plan only pays up to a certain amount. If you choose to see an out-of-network dentist, you might be billed for any amount greater than what the Plan pays. Based on this information, we decided that the Plan's rules for coverage of prophylaxis, a periodic oral evaluation, bitewings, and fluoride varnish with an out-of-network provider has been correctly applied. The total amount you are being asked to pay is $196. Therefore, we decided that the Plan has applied the correct cost sharing amount for prophylaxis (D1110), a periodic oral evaluation (D0120), bitewings (D0274), and fluoride varnish (D1206) provided by a non-participating provider on June 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve visits with a neurosurgeon to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the OON neurosurgeon visits. You say that the enrollee saw a different provider at the same facility. The Plan denied your request. The Plan says there are no medical needs shown to justify treatment from an OON provider. The Plan says that there are network providers who can supply the services needed.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide neurosurgery consultation and treatment at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve visits with a neurosurgeon to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on December 20, 2017.
You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed for
medical necessity. The Plan denied your request. The Plan says this claim has been filed untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for the anesthesia services was not filed until April 30, 2021. This means that
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we
decided that the Plan does not have to pay for the anesthesia services provided on December 20, 2017.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aduhelm.

You asked the Plan to pre-approve Aduhelm. You say that the enrollee is a candidate for the new medication, Aduhelm, given intravenously monthly to stop the progression of their disease. You also say that it is your medical judgement that Aduhelm is warranted and medically necessary. The Plan denied your request. The Plan says the use of Aduhelm in this enrollee is not reasonable and necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Aduhelm. Our reviewer says that the documentation does not support that Aduhelm is medically reasonable and necessary for the enrollee in this case. Our physician reviewer found the case file does not contain any recent measurement of brain function. In addition, the magnetic resonance imaging (MRI) of the enrollee's brain suggests the presence of cerebrovascular disease, which is evidence of a mixed etiology for the enrollee's symptoms. Our reviewer found that it has not been shown that Aduhelm is at least as beneficial as existing and appropriate and available medically appropriate alternatives for this enrollee. Our physician reviewer also found that the documentation does not support that the Aduhelm is safe and effective for the 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 Aduhelm have not been met. Therefore, we decided that the Plan does not have to pre-approve Aduhelm.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CxBladder testing (0012M) provided on April 6, 2021.

You asked the Plan to pay for CxBladder testing. You say that this was medically necessary. The Plan denied
your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that non-coverage has been reaffirmed for codes
0012M and 0013M for CxBladder.

We looked at the file and Medicare rules. The testing at issue is not covered. Based on this information, we
decided that Medicare rules for coverage of CxBladder testing have not been met. Therefore, we decided that
the Plan does not have to pay for CxBladder testing (0012M) provided on April 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facial contouring surgery and a chondrolaryngoplasty.

You asked the Plan to pre-approve the procedures. You say that this is medically necessary. The Plan denied your request. The Plan says the requested services are cosmetic.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the procedures. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested surgical procedure(s) are not medically necessary to correct or improve a functional problem in this case (i.e., to repair or treat an accidental injury or to improve the function of a malformed body member). The clinical documentation supports that the requested surgical procedure(s) are directed at improving the enrollee's appearance. 

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 procedures have not been met. Therefore, we decided that the Plan does not have to pre-approve facial contouring surgery and a chondrolaryngoplasty.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) provided by an out-of-network
provider.
You asked the Plan to pre-approve a crown. You say that you believe that a porcelain/ceramic crown is
medically necessary. The Plan denied your request. The Plan says these services must be provided by an innetwork
provider.
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 a crown when
the services are medically necessary and reasonable.
We looked at the file Medicare rules. Based on this information, we decided that the Plan's rules for coverage
of a crown have not been met. Specifically, the requested dentist is not in-network with the Plan. Therefore, we
decided that the Plan does not have to pre-approve a crown (D2740) provided by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found there are no identifiable skilled nursing or skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for unclassified drugs (J3490) provided on July 31, 2020.

You asked the Plan to pay for unclassified drugs. You say that similar claims have been paid. The Plan denied your request. The Plan says this was not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that when submitting a claim for not otherwise classified (NOC) drugs, the drug's name and dosage should be entered in item 19 on the claim form. 

We looked at the file and Medicare rules. The name and dosage of the NOC drug at issue was not entered in item 19 on the claim form. Based on this information, we decided that Medicare rules for coverage of unclassified drugs have not been met. Therefore, we decided that the Plan does not have to pay for unclassified drugs (J3490) provided on July 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient services provided October 10, 2020.

You asked the Plan to pay for the outpatient services. You say that the claim was denied due to credentials. Please review claim as your credentials were approved and should be processed per APC rates. The Plan denied your request. The Plan says provider ineligible. No Medicare ID on file for this provider.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the outpatient services provided October 10, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic activities coded 97530 provided on February 17, 2020.

You asked the Plan to pay for the therapeutic activities. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. 

We find that CPT code 97530 is not supported in the medical record. Specifically, the documentation shows that an occupational therapy assistant visit in the home setting was performed. There is a more appropriate code to be billed for the services rendered. Based on this information, we decided that Medicare rules for coverage of the therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic activities coded 97530 provided on February 17, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the immunohistochemistry or immunocytochemistry services (88341 and 88342) provided on February 13, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the immunohistochemistry or immunocytochemistry services. You say that the enrollee's healthcare provider took the specimens at their office and sent them to your laboratory for analysis. You also say that you request this claim to be reconsidered because the service you billed for was referred to you by an authorized provider. The Plan denied your request. The Plan says these services were rendered by a non-participating provider, and the referring provider is out-of-network. The Plan also says that prior authorization 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 the immunohistochemistry or immunocytochemistry services (88341 and 88342) provided on February 13, 2021 by an out-of-network (OON) provider
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (ECG) report (93010), provided on March 3, 2021.
You asked the Plan to pay for the ECG report. You say that the service should be covered. The Plan denied your request. The Plan says the member was enrolled in a hospice program during the date of this service.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the electrocardiogram (ECG) report (93010), provided on March 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent observation care provided on February 1, 2021.

You asked the Plan to pay for subsequent observation care. You say that the physician provided medically
necessary services in good faith, and the rendered services meet professionally recognized standards of
healthcare. The Plan denied your request. The Plan says the enrollee must receive care from in-network
providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service
area or if the care cannot be provided with an in-network provider, which requires prior authorization from the
Plan.

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
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 subsequent observation care provided on February 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on May 13, 2021.
You asked the Plan to pay for the testing services. You say that the provider ordered the testing to determine if
there was a more effective therapy to treat the advanced cancer. The Plan denied your request. The Plan says
the testing as billed was not medically necessary.
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 looked at the file and the rules. In this case, there are insufficient medical records to show the indications
for coverage have been met. Furthermore, if a single procedure is performed, only one HCPCS/CPT code with
one unit of service may be reported for the procedure. Based on this information, we decided that Medicare
rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have
to pay for the Guardant360 testing provided on May 13, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for sleep studies provided on November 23, 2020, and November 24, 2020.
You asked the Plan to waive the copayments for sleep studies. You say that you feel like there should not be separate charges for the services. 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 a $0 copayment for electrocardiograms and diagnostic colonoscopy screenings and a $200 copayment for all other diagnostic procedures and tests.
You received a sleep study on November 23, 2020. Therefore, you are responsible to pay the $200 copayment. You received a sleep study on November 24, 2020. Therefore, you are responsible to pay the $200 copayment. The total amount you owe is: $400. You have been asked to pay the total copayment amount of $400 for sleep studies. Sleep studies fall within the outpatient diagnostic tests and therapeutic services and supplies 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 copayments for sleep studies provided on November 23, 2020, and November 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for biopsy or excision of lymph node(s) coded 38510 provided on March 4, 2021.

You asked the Plan to pay for biopsy or excision of lymph node(s). You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. 

In this case, the MUE for CPT code 38510 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of biopsy or excision of lymph node(s) have not been met. Therefore, we decided that the Plan does not have to pay for biopsy or excision of lymph node(s) coded 38510 provided on March 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fabrication of an athletic mouthguard (D9941), provided on May 20, 2021.

You asked the Plan to pay for the fabrication of an athletic mouthguard. You say that the item should be covered. The Plan denied your request. The Plan says this service is not a covered benefit.

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 fabrication of an athletic mouthguard (D9941), provided on May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on May 21, 2021.

You asked the Plan to pay for these services. You say that the provider did not question your insurance or mention that they were not a network provider. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.

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 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 out of network physician services provided on May 21, 2021.