Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided March 28, 2021 to April 26, 2021.
You asked the Plan to pay for the SNF services. You say that you feel that the SNF services should be covered by the Plan. The Plan denied your request. The Plan says the Medicare criteria for continued SNF level of coverage were not 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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided March 28, 2021 to April 26, 2021.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ground mileage (A0425) and emergency ambulance transport (A0427) provided on March 7, 2021.

You asked the Plan to pay for the ground mileage and emergency ambulance transport. You say that this is not a duplicate claim, and the enrollee had two ambulance transports on this same date of service. The Plan denied your request. The Plan says that this claim is a duplicate claim.

The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied, but such denials may be appealed. 

We looked at the file and Medicare rules. Evidence was provided that this claim was not a duplicate. Based on this information, we decided that Medicare rules for coverage of the ground mileage and emergency ambulance transport have been met. Therefore, we decided that the Plan has to pay for the ground mileage (A0425) and emergency ambulance transport (A0427) provided on March 7, 2021.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device (E0675) and sleeves (E0673) provided to the enrollee on September 24, 2020.

You asked the Plan to pay for the pneumatic compression device and sleeves. You say that you would like this claim to be reevaluated. The Plan denied your request. The Plan says that this is a non-covered benefit.

The Plan follows Medicare rules. The rules state that a Pneumatic Compression Device (PCD) coded as E0675 to treat peripheral arterial disease (PAD) is not eligible for reimbursement 

We looked at the file and Medicare rules. Specifically, this item is not a covered benefit of Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (E0675) and sleeves (E0673) provided to the enrollee on September 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for removal of previously implanted intrathecal or epidural
catheter services provided on March 9, 2020.
You asked the Plan to pay for removal of previously implanted intrathecal or epidural catheter services. You
say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the
claim was submitted 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 removal of previously implanted intrathecal or epidural catheter services was
not filed until May 3, 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 removal of previously
implanted intrathecal or epidural catheter services provided on March 9, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a full hereditary cancer panel (81317, 81404, 81405, 81406, 81407, 81408, 81162, 81479, 81403, 81308, 81435, 81437) provided on October 13, 2020.

You asked the Plan to pay for a full hereditary cancer panel. You say that this is supported by the records. The Plan denied your request. The Plan says this was not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. If a laboratory assays 2 or more genes in a patient in parallel, then those 2 or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so 1 code must be submitted for the panel. 

We find that CPT codes 81317, 81404, 81405, 81406, 81407, 81408, 81162, 81479, 81403, 81308, 81435, and 81437 are not supported in the medical record. Specifically, these codes were used to report a panel, which should be billed with a single code. Based on this information, we decided that Medicare rules for coverage of a full hereditary cancer panel have not been met. Therefore, we decided that the Plan does not have to pay for a full hereditary cancer panel (81317, 81404, 81405, 81406, 81407, 81408, 81162, 81479, 81403, 81308, 81435, 81437) provided on October 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (G0483) provided to the enrollee on April 12, 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 Healthcare Common Procedure Coding System (HCPCS) code G0483 remains not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We find that HCPCS code is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 drug testing services (G0483) provided to the enrollee on April 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services provided on May 4, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the OON services. You say that you are unable to get authorization for the enrollees. The Plan denied your request. The Plan says the services were not urgent, emergent, or 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 provider in this case is not a network provider with the Plan. The referring provider was not a network provider with the plan. The Plan had network providers available who could have provided the services at issue in this appeal. 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 the x-ray services provided on May 4, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a peri-auricular stimulation (P-Stim) device for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that this service is not a covered Medicare benefit because acupuncture for auricular stimulation does not meet the definition of reasonable and necessary.

The Plan must follow Medicare rules. Medicare rules say that auricular PNS is not covered by Medicare as it is not considered medically reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve a peri-auricular stimulation (P-Stim) device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on February 24, 
2021, and the filling (D2394) provided on March 29, 2021. You asked the Plan to pay for the evaluation and filling. You say that you pay your premiums to have this 
insurance and do not understand why these simple services are not covered. The Plan denied your request. The 
Plan says limited oral evaluations are not listed as a service covered by your dental benefit. The filling has been 
covered by the Plan, but you are responsible for 50% coinsurance for this service. These claims were processed 
correctly based on your benefits. 
 
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 rules say a plan must 
disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles 
and coinsurance). Your contract with the Plan clearly says that you must pay 50% coinsurance for restorations 
(fillings) received from an in-network provider. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested limited oral evaluation is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation (D0140) provided on February 24, 2021.  
 
You have been asked to pay $134 for the filling. The provider billed $268 for this service, which is also the 
Plan's allowed amount for this service. The Plan has paid $134 for your filling, and you are being asked to 
cover the remaining 50% of the cost. Restorations (fillings) require 50% coinsurance. 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 pay any additional amount or waive the coinsurance for the filling (D2394) provided on March 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on May 5, 2021.
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you were referred to this dentist for an implant and they took the x-ray, but they were unable to do the implant. You also say that you were then referred to another dentist for the implant who took another x-ray. The Plan denied your request. The Plan says you were covered for a panoramic x-ray series on a previous claim.
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, intraoral complete series, vertical bitewings, and panoramic radiographic image share a frequency limitation of one every 36 months. The record shows that you received a panoramic x-ray (D0330) on May 5, 2021 and your intraoral complete series, vertical bitewings, and panoramic radiographic image benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on May 5, 2021.
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 this request is medically necessary. The Plan denied your request. The Plan says the medical records do not support that the member meets the criteria for coverage.
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 requested drug is not medically reasonable and necessary. Our physician reviewer found Aduhelm is indicated for the treatment of Alzheimer's disease in patients with mild cognitive impairment or mild dementia stage of disease. The documentation is insufficient to demonstrate that Aduhelm is medically reasonable and necessary for the enrollee in this case as there is no evidence of a neurological examination. 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 the infectious agent detection by nucleic acid services coded
87641.
You asked the Plan to pay for the infectious agent detection by nucleic acid services. 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
separately payable.
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, we have confirmed that code 87641
for the infectious agent detection by nucleic acid services has a bundled relationship with code 87150 and
cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted,
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the
infectious agent detection by nucleic acid services coded 87641.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sanexas services rendered from December 23, 2020 to 
December 31, 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 the services are not covered. 
 
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.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the Sanexas services rendered from December 23, 2020 to December 31, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the positron emission tomography (PET) scan rendered on 
May 1, 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 claim was not billed with a valid diagnosis code. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with an appropriate 
diagnosis code. 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 positron emission tomography 
(PET) scan rendered on May 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions (D7210 x 2) and full mouth x-ray (D0210) provided on April 1, 2021.
You asked the Plan to pay for the extractions and full mouth x-ray. You say that you would like coverage for all items on the claim in question. You also say that you are not interested in paying for supplemental benefits at this time. The Plan denied your request. The Plan says extractions are not listed as covered service. The Plan says that 1 full mouth or panorax is covered every 36 months. The Plan also says that the frequency limit for this service has 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, the extractions are not among those covered under this benefit. Although the full mouth x-ray is listed as a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for the panoramic x-ray that you received on the date of service in this case, which shares a frequency limit with the full mouth x-ray. Therefore, we decided that the Plan does not have to pay for the extractions (D7210 x 2) and full mouth x-ray (D0210) provided on April 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a reclining chair.
You asked the Plan to pre-approve the chair. You say that this is medically necessary. The Plan denied your request. The Plan says this is a convenience item.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a reclining chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lenses (V2781) provided on May 3, 2021.
You asked the Plan to pay for progressive lenses. You say that this is the most expensive part of your new glasses and you need to have correct and effective vision. You also say you would like to appeal this decision and request reconsideration for coverage. The Plan denied your request. The Plan says progressive lenses are not a covered benefit.
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 says that eyewear does not include lens options, such as tints, progressive, transition lenses, polish, and insurance. We looked at the file and the Plan's rules. The progressive lenses which you purchased are not covered benefits of Medicare or the Plan. Based on this information, we decided that the Plan's rules for coverage of progressive lenses have not been met. Therefore, we decided that the Plan does not have to pay for progressive lenses (V2781) provided on May 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided November 5,
2020.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like this claim reprocessed
for medical necessity. The Plan denied your request. The Plan says there was no established relationship
between the provider and the enrollee.
The Plan follows Medicare rules. Medicare rules say that a lumbar-sacral orthosis is subject to the criteria listed
in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the lumbar-sacral orthosis. Our reviewer
says that the item was not medically reasonable and necessary. Our physician reviewer found that an
appropriate history and a physical examination of the back would reasonably be required to adequately assess
whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support
that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is
insufficient documentation of an appropriate evaluation of the enrollee and insufficient documentation of a
credible physical examination of the back.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the lumbar-sacral orthosis have not been met. Therefore, we decided that the
Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided November 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on February 3, 2021.
You asked the Plan to pay for the services provided. You say that the services are needed to keep infection out of your gums. The Plan denied your request. The Plan says the services are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The file shows that medicaments, gingival irrigation, and antimicrobial agents were provided. Although the Plan offers a dental benefit in excess of Medicare coverage, the services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services provided on February 3, 2021.