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

We decided that the Plan does not have to reimburse you for deluxe frames (V2021), progressive lenses (V2781) and anti-reflective coating (V2750) provided on May 21, 2021.
You asked the Plan to reimburse you for deluxe frames, progressive lenses and anti-reflective coating. You say that the amount you were reimbursed does not match the amount you submitted to the Plan. You also say you would like the claim to be reprocessed and paid. The Plan denied your request. The Plan says they will only reimburse one pair of glasses in the order the claim was received.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says that you receive a $200 (combined in and out-of-network) benefit toward the purchase and fitting of eyeglasses and pair of lenses or contact lenses, one per calendar year. We looked at the file and the Plan's rules. The records show you submitted two claims for the reimbursement of eyeglass frames and lenses. The Plan reimbursed you $189.97 on the first claim for frames. The records also show that the Plan reimbursed you the difference of $10.03 to reach the maximum allowed amount of $200 after receiving the 2nd claim. The records also show you exhausted your $200 maximum allowed benefit. The EOC confirms that you are responsible for costs above the plan approved amount. Based on this information, we decided that the Plan's rules for coverage of deluxe frames, progressive lenses and anti-reflective coating have not been met. Therefore, we decided that the Plan does not have to reimburse you for deluxe frames (V2021), progressive lenses (V2781) and anti-reflective coating (V2750) provided on May 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (88341) provided September 24, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 88341 is not supported in the medical record. Specifically, CPT 88341 is an add-on code. No valid primary code was billed. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (88341) provided September 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care and the advanced care planning provided on April 1, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility care and the advanced care planning. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 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. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care and the advanced care planning provided on April 1, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided April 22, 2021.
You asked the Plan to pay for the comprehensive oral exam. You say that it is unfair to be charged for the exam. Your old doctor was not a participating provider with the plan. The Plan denied your request. The Plan says you have exceeded the frequency limit for this service.
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 comprehensive oral exam once every three calendar years. We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive oral exam was previously covered on January 3, 2019. Based on this information, we decided that the Plan's
frequency limit for coverage of the comprehensive oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided April 22, 2021.
Your complaint about the Plan's coverage policy regarding frequency limits and network status of providers 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intracept procedure.
You asked the Plan to pre-approve intracept procedure. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
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 intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has low back pain. The intracept procedure is experimental for lower back pain. More research is needed to show safety and efficacy. Therefore, the enrollee does not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953), guided tissue regeneration (D4266), and interim partial denture (D5821), and to pay more for the two extractions (D7210 x2) provided on May 26, 2021.
You asked the Plan to pay for the bone replacement graft, guided tissue regeneration, and interim partial denture, or pay more for the two extractions. The Plan denied your request. The Plan says the bone replacement graft, guided tissue regeneration, and interim partial denture are not covered services. The Plan also says that the claim was processed correctly.
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 bone replacement graft, guided tissue regeneration, and interim partial denture are not among those covered under this benefit. You are responsible for a $31 copayment for each extraction (D7210). Therefore, we decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953), guided tissue regeneration (D4266), and interim partial denture (D5821), and to pay more for the two extractions (D7210 x2) provided on May 26, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services represented by code A0429 provided on October 1, 2020.
You asked the Plan to pay for code A0429. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. The rules say in a situation where the beneficiary dies, whether any payment under the Medicare ambulance benefit may be made depends on the time at which the beneficiary is pronounced dead by an individual authorized by the State to make such pronouncements. We looked at the file and Medicare rules. In this case, the file shows that the enrollee's time of death pronouncement was after dispatch and before the enrollee was loaded onboard the ambulance. Medicare payment is based on the provider's/supplier's BLS base rate, no mileage or rural adjustment is reported, and the provider/supplier must use the QL modifier when submitting the claim. In this situation, the correct CPT code to bill is A0428 for non-emergency services after assessment. Therefore, we decided that the Plan does not have to pay for the ambulance services represented by code A0429 provided on October 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81479) provided November 30, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. We looked at the file and Medicare rules. The records do not show an order for this test by the treating physician. The plan requested additional records, but none were received. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81479) provided November 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 20, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 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 services provided on August 20, 2020 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF)services.

You asked the Plan to pre-approve the SNF services. You say that the service is medically necessary. The Plan
denied your request. The Plan says the service is not medically necessary.

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 SNF services. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found you do not have any skilled nursing
or skilled therapy needs.

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 SNF services have not been met. Specifically, medically necessary services
can be obtained at a lower level of care. This means SNF care is not medically necessary or reasonable.
Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF)services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cervical Total Disc Arthroplasty (22856).

You asked the Plan to pre-approve Cervical Total Disc Arthroplasty. You say that the service is medically
necessary. The Plan denied your request. The Plan says Your records do not show that the enrollee has had an
advanced imaging study, a detailed picture study, within the past six months which shows that you have one of
the following problems. One, a nerve root in their spine is compressed by a ruptured disc or a growth of their
bone in their spine. Two, their spinal cord is compressed, or spinal canal is narrowed. The requested service is
not supported without one of these problems.

The Plan follows Medicare rules. Medicare rules say that the device must be approved by the FDA.

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 Cervical Total Disc Arthroplasty. Our
reviewer says that the service is not medically necessary. Our physician reviewer found cervical disc
replacement next to a previous fusion is experimental and the device is not FDA approved for use in this
manner.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Cervical Total Disc Arthroplasty have not been met. Therefore, we decided that
the Plan does not have to pre-approve Cervical Total Disc Arthroplasty (22856).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eysuvis drops 0.25% (J3490).

You asked the Plan to pre-approve Eysuvis drops. You say that the enrollee is stable on this medication. You also say that the enrollee has tried and failed other medications including, Alrex, artificial tear drops/gel, Cequa, loteprednol, and Xiidra. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs.

The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eysuvis drops 0.25% (J3490).

Benefits for Eysuvis drops 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).

You asked the Plan to pre-approve Vertiflex. You say that this treatment is considered safe and effective, and
the enrollee has failed conservative approaches to treatment. The Plan denied your request. The Plan says the
denial of authorization for this service is correct, because Vertiflex is considered experimental/investigational
and is not a standard of care.

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 Vertiflex. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the Vertiflex device is experimental. More research is needed to show its safety and efficacy.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have
to pre-approve insertion of an interspinous spacer device (Vertiflex).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Kanjinti.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has metastatic HER2 positive colon cancer. The Medicare-approved major drug compendia and National Comprehensive Cancer Network (NCCN) guidelines do not support the use of Kanjinti for this diagnosis. Kanjinti is not safe and effective or reasonable and medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Kanjinti.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.

You asked the Plan to pre-approve the SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do require skilled therapy services, but not on a daily basis or in an inpatient 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 SNF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means SNF care is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve photodynamic therapy (96567) and aminolevulinic acid HCl for topical administration (J7308).

You asked the Plan to pre-approve photodynamic therapy with aminolevulinic acid HCl. You say that the enrollee has a history of actinic keratosis. You also say that the enrollee has tried and failed liquid nitrogen. The Plan denied your request. The Plan says that the requested services are not reasonable or 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 photodynamic therapy with aminolevulinic acid HCl. Our reviewer says that the requested use of photodynamic therapy with amniolevulinic acid HCl is medically necessary. Our physician reviewer found the provided documentation supports that the enrollee meets criteria for photodynamic therapy with the use of aminolaevulinic acid HCl for topical treatment of the actinic keratoses (AK). The reviewer found that aminolaevulinic acid with photodynamic therapy is approved by the Food and Drug Administration (FDA) for the treatment of actinic keratoses. The National Coverage Determination states coverage includes topical drug therapy and photodynamic therapy without restrictions based on patient or lesion characteristics. Therefore, the reviewer found that the requested treatment is medically reasonable and 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 photodynamic therapy with amniolevulinic acid HCl have been met. Specifically, the record shows that the requested treatment is supported by the FDA and the National Coverage Determination. Therefore, we decided that the Plan has to pre-approve photodynamic therapy (96567) and aminolevulinic acid HCl for topical administration (J7308).

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.