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

We decided that the Plan does not have to pre-approve use of Prolia.
You asked the Plan to pre-approve Prolia. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for Prolia is correct, because the Plan requires a trial of zoledronic acid before it will approve Prolia.
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 Prolia. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Prolia. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drug of zoledronic acid. The record does not indicate that this drug would likely be less effective and/or have adverse effects for the enrollee. Based on the records provided there is no indication that the enrollee has a history of osteoporotic fracture. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Prolia.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on June 8, 2020.

You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be charged a copayment for the Covid-19 test. 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 $90 copayment per visit. 

You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency 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 the emergency room visit provided on June 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (G0481) provided on June 8, 2020.
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration because you have no knowledge of patient coverage prior to the specimen's arrival at the laboratory. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11.
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Specifically, the claim was submitted with a laboratory place of service code but the record indicates that the member received the face-to-face service in an office setting. Therefore, we decided that the Plan does not have to pay for drug testing services (G0481) provided on June 8, 2020.
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 December 1, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you believe this service should be covered. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit 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, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on November 25, 2020, and your problem focused limited oral evaluation (D0140) benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on December 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on January 19, 2021.
You asked the Plan to waive the copayment for a CT scan. You say that you were not aware that you would owe such a high copayment. 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 $275 copayment for diagnostic imaging. You have been asked to pay a $275 copayment for a CT scan. A CT scan falls within the outpatient diagnostic tests and therapeutic services and supplies 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 CT scan provided on January 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the positron emission tomography (PET) scan of the brain.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a brain PET is covered when specific criteria are met. 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 services are not medically necessary. Our physician reviewer found the records show that you were referred for a brain scan for evaluation of possible Lewy Body dementia versus Parkinson's disease. The requested brain PET scan is covered only to differentiate between Alzheimer's disease and fronto-temporal dementia. The records do not show that the PET scan is being requested for this purpose; therefore, the services are not medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the positron emission tomography (PET) scan of the brain.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request.
The Plan says rules for IRF care have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described 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 pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found you do not require the intensity of services provided at an IRF. Specifically, you are
not shown to require, or to be able to currently tolerate, fifteen hours per week of rehabilitative services with
regular physician evaluation. Your care needs can be met at a lower level of care in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two periodontal scalings and root planings.

You asked the Plan to pre-approve the scalings and planings. You say that you would like this service to be approved for coverage. 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 pre-approve two periodontal scalings and root planings.

Your complaint about being upset with the Plan's coverage is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a false tooth for a bridge (porcelain fused to predominantly base metal) (D6241) for tooth #12 and retainer crowns (D6751) for teeth #11 and #13.

You asked the Plan to pre-approve the false tooth and retainer crowns. You say that this service is medically
necessary, and you changed your Plan to ensure that this service would be covered. The related teeth have
already been extracted for this procedure because the extractions were already approved. The Plan denied your
request. The Plan says this service is not medically necessary and is beyond the scope of what the Plan covers.

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 Plan covers the false tooth
and retainer crowns when the services are medically necessary and reasonable.

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 false tooth and retainer crowns. Our
reviewer says that the requested services are beyond the scope of what the Plan covers. Our physician reviewer
found fixed bridgework can only be considered in the anterior region of the mouth to replace a single maxillary
anterior tooth or two adjacent mandibular anterior teeth. This appeal involves the replacement of a posterior
tooth with fixed bridge. This is beyond the scope of what the Plan covers.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the false tooth and retainer crowns have not been met. Therefore, we decided
that the Plan does not have to pre-approve a false tooth for a bridge (porcelain fused to predominantly base
metal) (D6241) for tooth #12 and retainer crowns (D6751) for teeth #11 and #13.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation or pay
more for the extraction provided on December 10, 2020, by an OON provider.
You asked the Plan to pay for the bone replacement graft and to pay more for the extraction. You say that you
were not aware that your Plan had a deductible. The Plan denied your request. The Plan says the bone
replacement graft is not a covered benefit, and these services were rendered by an OON provider. The Plan also
says that you are contractually obligated to pay $371.23 for the rendered dental procedures and the policy
deductible of $100.
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 bone replacement graft is not
among those covered under this benefit. The contract says that you also have a $100 deductible that you must
pay before the Plan will pay their share of the cost for your covered dental services. After you have met your
deductible, you are responsible for a 55% coinsurance for an extraction that is received OON. The Plan
contract also says that you are responsible for the difference between the billed amount and the Plan's share for
services rendered OON.
Billed Amount
for Extraction
Allowed
Amount
Deductible Difference of
Billed & Allowed
Amount
55%
Coinsurance
Member
Liability for
Extraction
$288 $99.48 $100 $88.52 $54.71 $243.23
You have been asked to pay $243.23 for the extraction and $128 for the bone replacement graft. The total
amount you owe for both services is $371.23 ($243.23 + $128 = $371.23). You have been asked to pay the
correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay
for the bone replacement graft for ridge preservation or pay more for the extraction provided on December 10,
2020, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray, or pay more for the comprehensive oral evaluation, bitewing x-rays, and prophylaxis provided on November 4, 2020 by an OON provider.

You asked the Plan to pay for the panoramic x-ray, and pay more for the comprehensive oral evaluation, bitewing x-rays, and prophylaxis. You say that you would like these services to be covered. The Plan denied your request. The Plan says panoramic x-ray is not a covered benefit. The Plan also says that the comprehensive oral evaluation, bitewing x-rays, and prophylaxis were performed by a non-participating provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the 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, panoramic x-ray is not among those covered under this benefit. The Plan contract says that you are responsible for a 50% coinsurance for each of the comprehensive oral evaluation, bitewing x-rays, and prophylaxis rendered OON. The contract also states that you are responsible for the difference between the billed amount and allowed amount for services that are received OON. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray, or pay more for the comprehensive oral evaluation, bitewing x-rays, and prophylaxis provided on November 4, 2020 by an OON provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the follow-up visit provided on December 9, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the follow-up visit. 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. Therefore, we decided that the Plan does not have to pay for the follow-up visit provided on December 9, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be received in other settings, for example: a skilled nursing facility.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for slurred speech Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81401, 81400, 81408, 81406) provided October
28, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the claim 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.

We find that CPT code 81401, 81400, 81408, 81406 is not supported in the medical record. Specifically, per
the Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative Coding Policy
Manual, if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory
shall report only one unit of service of one genomic sequencing procedure. If no CPT code accurately describes
the procedure performed, the laboratory may report CPT code 81479. In this case, one procedure was performed,
however multiple CPT codes were billed. Based on this information, we decided that Medicare rules for
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab
services (81401, 81400, 81408, 81406) provided October 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four bone replacement grafts (D4263 x4) and a guided tissue regeneration (D4266).

You asked the Plan to pre-approve the bone replacement grafts and guided tissue regeneration. You say that you would like these services to be approved for coverage. The Plan denied your request. The Plan says these services are not covered by your benefit 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 pre-approve four bone replacement grafts (D4263 x4) and a guided tissue regeneration (D4266).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodontal scaling and root planing.

You asked the Plan to pay for the scaling and planing. You say that you would like this service to be approved for coverage. 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 a periodontal scaling and root planing.

Your complaint about being upset with the Plan's coverage is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interlaminar interspinous process stabilization distraction device without open decompression or fusion (22869, 22870).
You asked the Plan to pre-approve the back procedure. You say that you highly recommend this minimally invasive procedure when conservative treatment has failed and as a safer alternative to a laminectomy or spinal fusion procedure. The Plan denied your request. The Plan says this service is considered experimental and/or investigational as there is not enough evidence demonstrating the safety and efficacy of these procedures or the effects of these procedures on the term health outcomes.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the back procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interlaminar interspinous process stabilization distraction device without open decompression or fusion (22869, 22870).