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

We decided that the Plan does not have to waive the copayment for a SNF stay provided form February 19, 2021, to March 15, 2021.

You asked the Plan to waive the copayment for a SNF stay. You say that you were there due to having the coronavirus and should not be responsible for the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 copayment for days 1-20 and a $100 copayment for days 21-100 for SNF care.

You had a SNF stay from February 19, 2021, to March 15, 2021. You are not being charged a copayment for days 1-20 (February 19, 2201, to March 10, 2021). You are responsible to pay a $100 copayment for days 21-24 (March 11, 2021, to March 14, 2021). The total amount you owe is: $100 (copayment) x 4 (SNF days) = $400. 

You have been asked to pay the total copayment amount of $400 for a SNF stay. A SNF stay falls within the SNF care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a SNF stay provided form February 19, 2021, to March 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6242) for tooth # 30 and two retainer crowns
(D6752) for teeth # 29 and 31.
You asked the Plan to pre-approve the dental services. You say that you pay extra for this dental coverage and
do not understand The Plan denied your request. The Plan says these services are not covered by your dental
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 pre-approve a
pontic (D6242) for tooth # 30 and two retainer crowns (D6752) for teeth # 29 and 31.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement denture.
You asked the Plan to pre-approve the replacement denture. You say that your dentist advised that they could
not fix your broken denture, because they are no longer in-network with your plan. You also say that you need
a new plate because you feel your current plate was faulty and not made correctly. The Plan denied your
request. The Plan says the records do not show that your current dentures are not broken beyond repair. The
Plan also says that your current denture is less than 60 months old.
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 replacement of removable and
fixed prostheses is covered only if the existing prostheses were inserted at least 60 months prior to the
replacement. The record shows that you received your current denture in March of 2020, and your denture
benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a replacement
denture.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tretinoin gel 0.01%.
You asked the Plan to pre-approve tretinoin. You say that the enrollee has been using this drug for over 2 years.
You also say that the enrollee has tried and failed tretinoin 0.1% cream. 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 selfadministered
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 tretinoin gel 0.01%.
Benefits for tretinoin 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 the Vertiflex Superion Interspinous device for the enrollee.
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied your request. The Plan says that indication for coverage is not met.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The vertiflex device is experimental. More research is needed. Our physician reviewer found the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Levulan Kerastick (J7308).
You asked the Plan to pre-approve Levulan Kerastick. You say that the enrollee is concerned about having procedures due to immunosuppression. 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 Levulan Kerastick (J7308).
Benefits for Levulan Kerastick 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the breathing capacity tests (94010), lung function test (94060), pulmonary function test (94726), membrane diffusion capacity (94729), transcutaneous quantitative hemoglobin (88728), pulmonary function tests by gas (94727), and pulmonary function tests oscillometry (94728) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the pulmonary function testing. You say that you want to go to a closer provider. The Plan denied your request. The Plan says the services are not emergent/urgent and are available within the member's 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the breathing capacity tests (94010), lung function test (94060), pulmonary function test (94726), membrane diffusion capacity (94729), transcutaneous quantitative hemoglobin (88728), pulmonary function tests by gas (94727), and pulmonary function tests oscillometry (94728) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital observation
provided from October 13, 2020, to October 23, 2020.
You asked the Plan to waive the copayment for the outpatient hospital observation. You say that you have
never had a copayment. The Plan denied your request. The Plan says you have been asked to pay the correct
cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275
copayment for Medicare-covered outpatient hospital observation.
You have been asked to pay a $275 copayment for the outpatient hospital observation. The outpatient hospital
observation falls within the "Outpatient hospital observation" benefit category. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for the outpatient hospital observation provided from October 13, 2020, to October 23,
2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Nplate provided to the enrollee from April 23, 2019, to May 20, 2019.

You asked the Plan to pay for the Nplate. The Plan denied your request. The Plan says this drug was 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 pay for the Nplate. Our reviewer says that Nplate was not medically reasonable and necessary for the enrollee in this case. Our physician reviewer found that the goal of Nplate therapy is to keep the platelet count above 50,000. As the enrollee's platelet count was already above 50,000, Nplate was not 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 the Nplate have not been met. Therefore, we decided that the Plan does not have to pay for the Nplate provided to the enrollee from April 23, 2019, to May 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on March 23, 2021.
You asked the Plan to waive the copayment for a specialist telehealth visit. You say that you were told that the visit would be fully covered due to the coronavirus. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment per specialist telehealth visits. You have been asked to pay a $40 copayment for a specialist telehealth visit. A specialist telehealth visit falls within the telehealth services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on March 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for duplex scan of arterial inflow and venous outflow of
abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study (CPT code 93976) provided to
the enrollee on July 14, 2021.
You asked the Plan to pay for the service. You say that the services were rendered multiple times within the
date of service and should be paid. The Plan denied your request. The Plan says the service is not covered 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.
Our records indicate a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists
between 76856 and 93976. This PTP edit has a modifier indicator of 1, which indicates modifiers associated
with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit.
Therefore, we decided that the Plan does not have to pay for duplex scan of arterial inflow and venous outflow
of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study (CPT code 93976) provided
to the enrollee on July 14, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the pharmacogenetic testing provided on March 24, 2021.
You asked the Plan to pay for the testing services. You say that medical records prove medical necessity. The
Plan denied your request. The Plan says that Medicare denies coverage for all cardiovascular risk assessment
testing panels for suspected or documented cardiovascular disease.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The file shows that the enrollee received pharmacogenetic testing. The Plan denied services for cardiovascular
risk assessment testing. Furthermore, the Local Coverage Determinations and Articles (L36139, L36362,
L36523, A57055, and A57559) the Plan used in their decision to deny services are not binding in this case. Th
rules do not have Medicare Part B jurisdiction where the services were provided. The Plan has not made
reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your
request. Therefore, we decided that the Plan has to pay for the pharmacogenetic testing provided on March 24,
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial lower denture with flexible base (D5226).
You asked the Plan to pre-approve the dental item. You say that the requested partial denture is medically necessary. The Plan denied your request. The Plan says partial lower denture with flexible base is not listed as a covered service. The Plan also says that if a dental item or service is not listed in the benefit chart, then 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 requested lower partial denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a partial lower denture with flexible base (D5226).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for 4Kscore testing (81539) provided on March 5, 2021.
You asked the Plan to pay for 4Kscore testing. You say that you were told this was approved. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that due to significant issues with assay validation and absence of clinical utility, 4Kscore testing is not reasonable and necessary and is not covered by Medicare. We looked at the file and Medicare rules. The service at issue is not covered. Based on this information, we decided that Medicare rules for coverage of 4Kscore testing have not been met. Therefore, we decided that the Plan does not have to pay for 4Kscore testing (81539) provided on March 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the impacted tooth removal (D7240) for tooth #17 and #32.
You asked the Plan to pre-approve the impacted tooth removal (D7240). You say that you need the service because you can feel tension which gives you a headache and an uncomfortable feeling. The Plan denied your request. The Plan says the 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 pre-approve the impacted tooth removal (D7240) for tooth #17 and #32.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular diagnostic testing services provided on March 23, 2021.
You asked the Plan to pay for the services provided. You say that the screening for cervical cancer is covered as billed. The Plan denied your request. The Plan says molecular genetic screening testing is not a Medicare benefit for the diagnoses listed.
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. We looked at the file and the rules. Cervical and vaginal cancer screening is a covered benefit. However, the genetic testing provided is not. The test at issue in this appeal, the genetic testing, was requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the molecular diagnostic testing services provided on March 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 22, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable 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 the laboratory services are is not supported in the medical record. Specifically, when a laboratory assays two or more genes in an enrollee in parallel, those two or more genes will be considered part of the same panel. A panel constitutes a single procedural code, so one code must be submitted for the panel. Review of the file shows that more than one code was submitted for these services.
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not
been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on
February 22, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from April
20, 2021, to April 30, 2021.
You asked the Plan to pay for the SNF care. You say that the services are coverable under the Medicare Act.
The Plan denied your request. The Plan says the enrollee was no longer receiving daily skilled services during
the dates of service in this case.
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 care. Our reviewer says that the
enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not
have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled
professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill,
knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing
and/or skilled therapy on an inpatient basis in a SNF 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, the file shows that the enrollee
did not receive daily skilled services during the dates of service in this case. Therefore, we decided that the
Plan does not have to pay for the skilled nursing facility (SNF) care provided from April 20, 2021, to April 30,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a So Clean device.
You asked the Plan to pre-approve the item. You say that this is needed to clean a positive airway pressure device. The Plan denied your request. The Plan says this item does not serve a medical purpose and would be considered 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 So Clean device.