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

We decided that the Plan does not have to reimburse you for massage therapy provided by a Licensed Massage Therapist from March 27, 2021, to April 20, 2021.
You asked the Plan to reimburse you for therapeutic procedure (97124), manual therapy (97140), therapeutic procedure (97112). You say that you want to be reimbursed for the massage therapist sessions. The Plan denied your request. The Plan says these services when not performed by a chiropractor are not covered by the Plan's additional benefit.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. However, the Plan offers an additional chiropractic benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
The records show that the services at issue were not provided by a chiropractor. Therefore, we decided that the Plan does not have to reimburse you for massage therapy provided by a Licensed Massage Therapist from March 27, 2021, to April 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral complete series of radiographic images (D0210) and comprehensive oral exam (D0150), provided on February 4, 2021.
You asked the Plan to pay for the routine dental services. You say that the services should be covered. The Plan denied your request. The Plan says you have exhausted your Plan benefit for these services.
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. Specifically, you have already exhausted the Plan benefit for the services requested. Therefore, we decided that the Plan does not have to pay for the intraoral complete series of radiographic images (D0210) and comprehensive oral exam (D0150), provided on February 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for targeted genomic sequence analysis, solid organ neoplasm,
DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, gene
rearrangements, microsatellite instability and tumor mutational burden (CPT code 0037U) provided to the
enrollee on April 21, 2021.

You asked the Plan to pay for the laboratory testing. You say that the enrollee was newly diagnosed with
advanced cancer and needed the test performed immediately to help determine their treatment. The Plan denied
your request. The Plan says the clinical information provided does not indicate the requested test is part of the
care plan or how it would impact the care plan as the treatment has already been decided.

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 laboratory testing. Our physician
reviewer found the review indicates that the pathology reports the enrollee has small cell carcinoma found after
mediastinal lymphadenopathy was noted. The submitted form of April 8, 2021, states the Stage is four (IV), so
the element (i) is met. The office note of April 6, 2021, mentions starting atezolizumb, carboplatin, etopiside on
April 6, with additional chemo for April 7, 2021, and April 8, 2021. The notes do not mention needing the
results of the NGS to determine appropriate treatment. The enrollee was started on immunotherapy of
Tecentriq (atezolizumb). The note mentions "if no improvement, radiation." The note does not mention a need
for NGS. The medical records provided do not meet the requirements listed in the NCD for Medicare coverage.

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 laboratory testing have not been met. Therefore, we decided that the Plan
does not have to pay for targeted genomic sequence analysis, solid organ neoplasm, DNA analysis of 324
genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements,
microsatellite instability and tumor mutational burden (CPT code 0037U) provided to the enrollee on April 21,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on April 20, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. You say that these services were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that the referring provider is also out-of-network.
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 physician services provided on April 20, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. You say that you cannot walk or stand. The Plan denied your request. The Plan says your needs can be provided at a lower level of care.
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 SNF services. Our physician reviewer found that you are at a minimal assist level for bed mobility and transfers, supervision with a four-wheeled walker. You have no skilled nursing needs. You do not require skilled therapy services on a daily basis 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve the SNF services. You say that SNF services are medically necessary. The Plan denied your request. The Plan says SNF services are 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 medically necessary. Our physician reviewer found that you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, you do not require the necessary services on 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-ray and panoramic x-ray provided on May 20, 2021.
You asked the Plan to pay for the intraoral x-ray and panoramic x-ray. You say that the procedure was necessary because of new patient status. You say that you are appealing the denied services. The Plan denied your request. The Plan says one complete series or panoramic x-rays is covered every three calendar years.
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, you also have a maximum benefit of one complete series x-ray or panoramic x-ray every five years. The Plan paid for a panoramic x-ray provided on October 30, 2019, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the intraoral x-ray and panoramic x-ray provided on May 20, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Nivolumab.
You asked the Plan to pre-approve Nivolumab. You say that the current medical recommendation is that the enrollee continues on the current regimen. The Plan denied your request. The Plan says that documentation is needed to show the enrollee's cancer is responding to treatment.
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 Nivolumab. Our physician reviewer found that the enrollee has muscle invasive bladder cancer and adenocarcinoma of the upper gastrointestine. There is primary metastasis to the liver. The requested use of Nivolumab is FDA approved for the enrollee's diagnosis. The use is not listed as not indicate, not supported, or not recommended in any of the compendia. The documentation does support 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 Nivolumab have been met. Therefore, we decided that the Plan has to pre-approve Nivolumab.
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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the inhalation of nitrous oxide (D9230) provided on May 24, 2021.
You asked the Plan to pay for the dental service. You say that you have to use nitrous as you are not able to use your medication beforehand. You say that you had a reaction to the shots previously. You say that the Plan has covered this service in the past. You also say that you are on disability and cannot afford to pay out of pocket. The Plan denied your request. The Plan says nitrous oxide is not listed as a covered service. The Plan also says that the provided records did not indicate there was a medical need for this service, therefore it 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 inhalation of nitrous oxide is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the inhalation of nitrous oxide (D9230) provided on May 24, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998)
provided on March 28, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you did not want
to be transported as you were feeling better and you planned on calling your physician. The Plan denied your
request. The Plan says actual transportation to an approved destination must occur for ambulance services to be
covered.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on March 28, 2021. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport
(A0998) provided on March 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panels (CPT code(s): 81407, 81408, 81479 and 81439) provided to the enrollee on November 9, 2020.
You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. Medicare guidance says Medicare denies coverage for all cardiovascular risk assessment panels for patients with suspected or documented cardiovascular disease. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panels (CPT code(s): 81407, 81408, 81479 and 81439) provided to the enrollee on November 9, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) admission provided from
January 8, 2021, to January 11, 2021.
You asked the Plan to pay for the SNF admission. You say that the services are coverable under the Medicare
Act. The Plan denied your request. The Plan says the enrollee did not receive any skilled care on the dates of
service in this case. The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from
trained medical or paramedical staff, is not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the SNF admission have not been met. Specifically, we find that the services at issue in this case
are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for skilled nursing
facility (SNF) admission provided from January 8, 2021, to January 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a pulmonary risk factor screening genetic panel (81302,
81330, 81345, 81406, 81407, 81408, 81479) provided on September 7, 2020.
You asked the Plan to pay for a pulmonary risk factor screening genetic panel. You say that this should be
covered. The Plan denied your request. The Plan says this is not a covered screening service.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal, a pulmonary risk factor screening genetic panel, was requested solely for
screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that
the Plan does not have to pay for a pulmonary risk factor screening genetic panel (81302, 81330, 81345, 81406,
81407, 81408, 81479) provided on September 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on January 15, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were
billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 the lab services provided on January 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a presbyopia correcting function of an intraocular lens (V2788) provided on May 11, 2021.
You asked the Plan to pay for a presbyopia correcting function.. You say that you would like the Plan to reconsider and pay for the services as in-network because the provider gave misleading information. The Plan denied your request. The Plan says this service is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives a P-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C IOL and a conventional IOL. While a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting feature of a P-C IOL. Therefore, we decided that the Plan does not have to pay for a presbyopia correcting function of an intraocular lens (V2788) provided on May 11, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. 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 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found documentation does not support the need for an admission to an SNF. The enrollee's rehabilitation needs can be met at a lower intensity level such as in a custodial care with intermittent therapies as needed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on May 5, 2021.
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that you believe that this claim was coded incorrectly. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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 comprehensive periodontal evaluation (D0180) provided on May 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the none-emergency transport, wheelchair van, (A0130), and the non-emergency transportation mileage (A0160) provided on February 21, 2021.

You asked the Plan to pay for the transportation services. You say that you needed transportation to a rehabilitation facility. You say that you were unable to get into a car. You say that you were not informed that you would be charged for this transportation. You also say that you feel you should not have to pay for this ride. The Plan denied your request. The Plan says transportation by wheelchair van is not covered by Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services.

The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided that the Plan does not have to pay for the none-emergency transport, wheelchair van, (A0130), and the non-emergency transportation mileage (A0160) provided on February 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services (70544) provided to the enrollee on April 26, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says an appropriate modifier was not billed in this case.
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 70544 is "Magnetic resonance angiography, head." We asked our coder 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the provider billed CPT 70544 with CPT 70553 without appropriate modifier. NCCI-associated modifiers are used to indicate the special circumstances such as when the procedures are performed at different anatomic sites, a separate procedure or repeat clinical diagnostic laboratory test. If an edit allows use of NCCI-associated modifiers, the two procedure codes may be reported together. This CPT code would not be covered without appropriate modifier appended.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for imaging services (70544) provided to the enrollee on April 26, 2021.