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

We decided that the Plan does not have to pay an additional amount for periodontal scaling and root planing (D4341), an extraction (D7210), and an unspecified preventive procedure (D1999) provided on February 15, 2021.

You asked the Plan to pay an additional amount for periodontal scaling and root planing, an extraction, and an unspecified preventive procedure. You say that you want the Plan to pay for the services. The Plan denied your request. The Plan says the benefit maximum had already been met before this date. Additionally, an unspecified preventive procedure 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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of periodontal scaling and root planing, an extraction, and an unspecified preventive procedure have not been met. Specifically, the record shows that you had exhausted your dental benefit maximum of $1000. Additionally, an unspecified preventive procedure is not a covered benefit. Therefore, we decided that the Plan does not have to pay an additional amount for periodontal scaling and root planing (D4341), an extraction (D7210), and an unspecified preventive procedure (D1999) provided on February 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory tests provided by an out-of-network provider on January 4, 2021 and January 11, 2021.
You asked the Plan to pay for the laboratory tests. You say that the Plan follows Medicare billing guidelines which does not require prior authorization for this test. You say that the claim should be processed for payment. The Plan denied your request. The Plan says this provider is not a participating provider with the Plan.
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 laboratory tests provided by an out-of-network provider on January 4, 2021 and January 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.You asked the Plan to pre-approve foot orthotics. You say that you are in a lot of pain.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Vectibix.

You asked the Plan to pre-approve Vectibix. You say that this request is medically necessary. The Plan denied your request. The Plan says that the criteria for coverage have not been met.

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 Vectibix. Our reviewer says that the requested service is medically necessary. Our physician reviewer found the enrollee has been diagnosed with metastatic colon cancer KRAS wild type. Although Vectibix is not FDA-approved for the enrollee's diagnosis, there is support in a Medicare-approved compendia for the use of Vectibix for the enrollee's medical condition. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vectibix have been met. Therefore, we decided that the Plan has to pre-approve Vectibix.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit with an out-of-network gynecologist.
You asked the Plan to pre-approve the out-of-network office visit. You say that this provider has taken care of you for 25 years. You say that you don't know what has changed but you want to see her. The Plan denied your request. The Plan says the service is available in-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 office visit with an out-of-network gynecologist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair and accessories.
You asked the Plan to pre-approve a Group 2 power wheelchair and accessories. You say that you need a Group 2 power wheelchair and accessories. The Plan denied your request. The Plan says the notes show you were evaluated, and a four wheeled walker meets your needs.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that your condition can be improved by a walker. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a neurostimulator (E0745) provided October 7, 2020.

You asked the Plan to pay for the neurostimulator. You say that the item was medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain a valid proof of delivery. No itemized shipping documentation was provided. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a neurostimulator (E0745) provided October 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to pre-approve a computed tomography (CT) scan for the enrollee.
You asked the Plan to pre-approve a CT scan. You say that a CT scan was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria. The Plan notes the enrollee was asymptomatic and requested the CT scan be done as a screening prior to a trip to Hawaii. The enrollee had recovered from Covid-19 and wanted to confirmation the respiratory issues were clear. The Plan states this was a screening and was not medically necessary.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. The medical records show the enrollee was asymptomatic and the test was done for precautionary or screening purposes prior to travel for leisure. Based on this information, we decided that Medicare rules for coverage of a CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the thorax for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hearing exam nor remove the charge for
the hearing aid adjustment provided on February 17, 2021.
You asked the Plan to waive the copayment for the hearing exam. You say that your insurance card and policy
show a $0 cost for Medical Care Office which includes hearing. The Plan denied your request. The Plan says
you were charged less than the required $35 copayment. The Plan also says they did not receive a claim for the
hearing aid adjustment however you used your 3 benefit included visits in 2018.
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 $35
copayment for Hearing Services and Hearing Aids.
You have been asked to pay a $25 copayment for the hearing exam. The provider charged you less than the
required copayment. The hearing exam falls within the Hearing Services category. This means that you have
been asked to pay less than 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. The Plan did not receive a claim for the
hearing aid adjustment service. Therefore, we decided that the Plan does not have to waive the copayment for
the hearing exam nor remove the charge for hearing aid adjustment provided on February 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) provided on
December 22, 2020, by an OON provider.

You asked the Plan to pay for the domiciliary or rest home visit. You say that the medical records provided
support the necessity of the services in dispute. The Plan denied your request. The Plan says enrollee's must
receive their medical services from an in-network provider with the exception being urgent or emergent
services. Non-emergent services with non-contracted providers require prior authorization before services
being rendered.

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 domiciliary or rest home visit (99335)
provided on December 22, 2020, by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services represented by code 97110 provided on January 15, 2020.

You asked the Plan to pay for code 97110. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT code 97110 is not supported in the medical record. Specifically, the records indicate that the services were performed by a physical therapist in a home health or hospice setting. There is a more appropriate code for the services provided in a home health setting. Based on this information, we decided that Medicare rules for coverage of code 97110 have not been met. Therefore, we decided that the Plan does not have to pay for the therapy services represented by code 97110 provided on January 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on October 19, 2020.

You asked the Plan to pay for the services provided. You say that you have no knowledge of the enrollee's coverage prior to the specimen's arrival at the lab. The Plan denied your request. The Plan says the billed code cannot be verified.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.

We looked at the file and the rules. The claim provided shows the place of service as an independent lab. The records do not indicate the enrollee's specimen was obtained by an independent lab. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on October 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Volara system.

You asked the Plan to pre-approve the Volara system. You say that this request is medically necessary. The Plan denied your request. The Plan says this item is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 

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 Volara system. Our reviewer says that the requested item is not medically necessary and reasonable. Our physician reviewer found the specific Volara system is considered not medically necessary. This patient has bronchiectasis and meets criteria for high-frequency chest wall oscillation, but this is not what is being requested. There is insufficient evidence that the Volara system is effective and safe in the treatment of bronchiectasis. 

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 Volara system have not been met. Therefore, we decided that the Plan does not have to pre-approve the Volara system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 7.
You asked the Plan to pre-approve the dental service. You say that this service is medically necessary. The Plan denied your request. The Plan says core build up is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
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 core build up (D2950) for tooth # 7.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient dialysis services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the dialysis services. You say that the enrollee has been receiving treating with you since September 2017. The authorization on will expire 5/10/21. You need to renew this authorization as the enrollee will be treating with you indefinitely. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 outpatient dialysis services to be provided 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 December 28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab tests. You say that it is beyond your control if authorization was obtained because you do not see the enrollee personally. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and the ordering provider is also out-of-network with the Plan.
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 laboratory testing provided on December 28, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown -porcelain/ceramic (D2740).You asked the Plan to pre-approve the crown -porcelain/ceramic (D2740). You say that you do not want to have a metal crown due to your history of allergies.The Plan denied your request. The Plan says the requested service is not covered under your supplemental 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 crown -porcelain/ceramic (D2740).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.

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 Ondansetron.

Benefits for these services 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 12, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 12, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-one (J7326).
You asked the Plan to pre-approve Gel-one. The Plan denied your request. The Plan says the information submitted does not meet the Plan's medical necessity guidelines for coverage.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Gel-one. Our reviewer says that Gel-one (J7326) does not meet coverage criteria. Our physician reviewer found based on the medical records provided the patient has not tried and failed the required drugs, Orthovisc and Monovisc. Our reviewer also found that there is no indication that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gel-one have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-one (J7326).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone replacement grafts (D7953) and therapeutic drugs (D9610).You asked the Plan to pre-approve bone replacement grafts and therapeutic drugs. You say that these services are necessary, and you cannot afford them.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 bone replacement grafts (D7953) and therapeutic drugs (D9610).