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

 We decided that the Plan does not have to pay for the panoramic x-ray (D0330), prophylaxis (D1110), four anterior resin-based composites (D2330 x4), posterior resin-based composite (D2391), periodontal scaling and root planing (D4341), 11 simple extractions (D7140 x2), and inhalation of nitrous oxide/analgesia (D9230) provided from July 30, 2021, to August 31, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the panoramic x-ray, prophylaxis, resin-based composites, scaling and planing, extractions, and inhalation of nitrous oxide/analgesia. You say that you went OON because you were scheduled to have a heart valve replacement and none of the in-network providers in your area could get you in beforehand. You also say that if you did not have this dental work completed, you would have had to delay the heart valve replacement. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that prior authorization was not requested to see this dental provider and there were no phone calls made to the Plan to verify the provider's participation status.  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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330), prophylaxis (D1110), four anterior resin-based composites (D2330 x4), posterior resin-based composite (D2391), periodontal scaling and root planing (D4341), 11 simple extractions (D7140 x2), and inhalation of nitrous oxide/analgesia (D9230) provided from July 30, 2021, to August 31, 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 broken complete maxillary denture base repair (D5512) provided on April 20, 2021.  

You asked the Plan to pay for the broken complete maxillary denture base repair. You say that when you were in the office on this date of service you were not advised that your insurance would not cover this bill. You also say that if you had known your insurance would not cover this procedure, you would not have had it done. 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 broken complete maxillary denture base repair (D5512) provided on April 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services provided on April 27, 2021.  

You asked the Plan to pay for the services provided. You say that the service was done for the safety of the enrollee. The Plan denied your request. The Plan says deep sedation was not achieved.  

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 01200 is anesthesia for all closed procedures involving hip joint. We find that CPT code 01200 is not supported in the medical record. Specifically, the records show that the enrollee received monitored anesthesia care (MAC) services. The billed code is not appropriate for the services provided. There is a more comprehensive code for the services at issue.  

Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on April 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on June 24, 2021, by an 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 June 24, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on April 1, 2021.  You asked the Plan to pay for the problem focused limited oral evaluation. You say that this was an emergency visit due to a severe toothache. The Plan denied your request. The Plan says this service is not covered under your policy.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on April 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the two retainer crowns (D6740 x2) provided on August 17, 2021  You asked the Plan to pay for the retainer crowns. You say that the provider's office quoted you a price for these procedures and then doubled your cost expectation after the work had begun. You also say that you would not have proceeded with the work if you had known the out-of-pocket cost was quoted at $4,000. The Plan denied your request. The Plan says this service is not a covered expense 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 two retainer crowns (D6740 x2) provided on August 17, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for acupuncture services provided on June 7 - July 12, 2021.  You asked the Plan to pay for the acupuncture services. You say that  The Plan denied your request. The Plan says the claims were denied because they were not billed with a diagnosis for chronic lower back pain.  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year.   We looked at the file and Medicare rules. The case file shows that the claims in dispute were billed with diagnosis codes related to shoulder pain. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Therefore, we decided that the Plan does not have to pay for acupuncture services provided on June 7 - July 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the flex-walk system (L5981).  You asked the Plan to pre-approve the flex-walk system. You say that this is medically necessary for your condition. The Plan denied your request. The Plan says the requested device exceeds the enrollee's needs.  The Plan follows Medicare rules. Medicare rules say that a flex-walk system or equivalent is covered for beneficiaries whose functional level is 3 or above (K3 ambulator).  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 flex-walk system. Our reviewer says that the requested flex-walk system is not medically reasonable and necessary. Our physician reviewer found the requested item exceeds the patient's medical need as the documentation indicates the patient uses a cane for ambulation with slight steppage tendency on the left and has a diagnosis of impaired endurance. This documentation therefore confirms that the enrollee's medical condition is not consistent with a K3 level of ambulation as required for the flex-walk system.  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 flex-walk system have not been met. Therefore, we decided that the Plan does not have to pre-approve the flex-walk system (L5981).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous glucose monitor.  You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cardiology services provided on April 15, 2021, by an out-of-network (OON) provider.  

You asked the Plan to pay for the cardiology services. You say that the services were 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 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 cardiology services provided on April 15, 2021, 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 removal of a torn knee cartilage service provided on July 29, 2021, by an out-of-network (OON) provider.  

You asked the Plan to pay for the removal of a torn knee cartilage service. You say that you are 100% covered with no copayments. You say your primary care physician followed protocol to be given permission to perform the knee surgery.  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 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 removal of a torn knee cartilage service provided on July 29, 2021, 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 ultrasonic guidance for needle placement (76942) provided on May 5, 2021.  You asked the Plan to pay for the ultrasonic guidance for needle placement. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says the provider did not bill as required by Medicare coding regulations.  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 76942 is a column II code to column I code 76937. This claim has not been billed with an appropriate modifier to bypass the edit. 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 ultrasonic guidance for needle placement (76942) provided on May 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on September 2, 2021.  

You asked the Plan to pay for the problem focused limited oral evaluation. You say that you feel that it is double billing because you paid for an evaluation with a general dentist and were referred to an oral surgeon. You also say that the oral surgeon charged you for the same evaluation that was already done, which should have only been done once. The Plan denied your request. The Plan says this service is not a covered benefit. The Plan also says that it was confirmed that you signed a financial agreement with the office, prior to the services being rendered, agreeing you would be responsible for the charges related to any non-covered 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. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on September 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the physician services provided on October 20, 2020 to October 31, 2020 by an out-of-network (OON) provider.  

You asked the Plan to pay for the physician 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 physician services provided on October 20, 2020 to October 31, 2020 by an out-of-network (OON) provider.
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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.  

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.   

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Aduhelm. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has a three-year history of progressive cognitive decline. The enrollee's medication list includes Donepezil. Mental status testing reportedly revealed evidence of mild to moderate abnormalities that do not meet the criteria for a dementia condition. It is noted that the enrollee has had some behavioral symptoms that could contribute to the enrollee's cognitive issues. Mini-Mental State Exam testing score was 27 which traditionally is considered normal. Magnetic resonance imaging (MRI) of the brain on June 15, 2021 demonstrated persistent moderate ventriculomegaly, slightly out of proportion to the degree of cerebral sulcal prominence. While this is similar to the previous study and likely related to a component of background atrophy, correlate for any clinical symptoms of mild communicating hydrocephalus. The documentation is inconsistent and does not demonstrate that the requested use of Aduhelm is FDA-approved for the enrollee's diagnosis. It has not been sufficiently demonstrated that Aduhelm is at least as beneficial as existing and appropriate and available medically appropriate alternatives 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 Aduhelm have not been met. Therefore, we decided that the Plan does not have to pre-approve Aduhelm.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hospital visit services provided on February 1, 2021, to February 28, 2021, by an out-of-network (OON) provider.  

You asked the Plan to pay for the hospital visit services. You say that the services were medically necessary, and the enrollee was not aware of his coverage. 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 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 hospital visit services provided on February 1, 2021, to February 28, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory testing provided on July 21, 2021.  

You asked the Plan to pay for lab tests. You say that you continue to do your part in providing timely testing and results. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because there is insufficient diagnosis/service information to support multiple infectious agent detection tests for common urinary tract infection concerns.  

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 pay for lab tests. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the documentation provided this was a simple - not complex - urinary tract infection (UTI), and there was no indication that the enrollee required an extensive organism search. There is insufficient diagnosis/service information to support multiple infectious agent detection tests for the patient's common UTI concerns. There is insufficient support that standard culture and sensitivity would not have been sufficient in this clinical situation.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on July 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the two cone beam computed tomography (CT) captures and interpretations (D0364 x2) provided on September 2, 2021.  You asked the Plan to pay for the cone beam CT captures and interpretations. 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 two cone beam computed tomography (CT) captures and interpretations (D0364 x2) provided on September 2, 2021.