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

We decided that the Plan does not have to pre-approve core buildups for the enrollee.
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan denied your request. The Plan says these services are either not covered, or not medically necessary.
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 dental services 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 dental services. Our reviewer says that the requested dental services are not medically reasonable or necessary. Our physician reviewer found the surgical extraction for tooth #28 and the crown for tooth #19 have been approved. As there is lack of documentation (radiographs are not included) the core buildups cannot be considered medically necessary. 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 dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve core buildups for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on December 4, 2018.
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your request. The Plan says there was no authorization.
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 the services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found based on the results of such testing, it appeared that buprenorphine had been prescribed which warrants periodic drug screening (presumptive UDT only). Upon review of the provided records, there was no clear indication for using definitive testing in this situation. There was no inconsistent results from prior testing, no evidence of a clinical need for determining more exact dosing, medication efficacy, side effects, or drug-drug interactions. Therefore, this request for definitive drug testing will be considered not medically necessary or appropriate.
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 services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services provided to the enrollee on December 4, 2018.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to make payment for the difference between the posterior resin-based composite - one surface on tooth #20 and the anterior resin-based composite - three surfaces on tooth #9 provided on August 6, 2019.
You asked the Plan to make payment for the difference between the resin-based composite on tooth #20 and the resin-based composite on tooth #9. You say that you would like the plan to reimburse for the filling done on tooth #9 because it was a higher cost filling. The Plan denied your request. The Plan says that the benefits for this service have been satisfied and the frequency limitation has been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers two restorations per year at 50% coinsurance when received by an in-network provider. The contract does not specify that the less expensive filling would be covered over a more expensive filling. Therefore, we decided that the Plan has to make payment for the difference between the posterior resin-based composite - one surface on tooth #20 and the anterior resin-based composite - three surfaces on tooth #9 provided on August 6, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says a shower chair is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services provided August 8, 2019 to October 10, 2019.
You asked the Plan to pay for the outpatient mental health services. You say that the services were necessary. The Plan denied your request. The Plan says the provider in this case is not eligible for Medicare payment.
The Plan must follow Medicare rules. Medicare rules say that Licensed Professional Counselors (LPC's) are not eligible for enrollment in the Medicare program. We looked at the file and Medicare rules. The provider is not eligible for Medicare payment. Based on this information, we decided that Medicare rules for coverage of the outpatient mental health services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient mental health services provided August 8, 2019 to October 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the periodontal maintenance (D4910) and the 2D oral or facial x-ray (D0350) provided on September 17, 2019.
You asked the Plan to pay the full amount for the periodontal maintenance and the 2D oral or facial x-ray. You say that your plan covers 100% of cleanings. You say that you had a general cleaning. You also say that you were not informed that the images would not be covered. The Plan denied your request. The Plan says periodontal maintenance is a covered service. The Plan says there is a 70% cost share for periodontal maintenance received in network. The Plan also says the 2D oral or facial x-ray is not 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 and periodontal maintenance is a covered service, there is a coinsurance of 70% that you pay when you receive the service in network. Additionally, the 2D oral or facial x-ray is not a covered service. Therefore, we decided that the Plan does not have to pay the full amount for the periodontal maintenance (D4910) and the 2D oral or facial x-ray (D0350) provided on September 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on July 11, 2019.
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says there is no valid referral for this service
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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a domiciliary or rest home visit provided on July 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the external ECG recording provided on September 17, 2019.
You asked the Plan to waive the copayment for the external ECG recording. You say that you were billed but did not have another ECG. The Plan denied your request. The Plan says the copayment applied correctly.
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 $10 copayment for diagnostic procedures and tests. You have been asked to pay a $10 copayment for the external ECG recording. The external ECG recording falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that the recording was interpreted on September 17, 2019. 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 external ECG recording provided on September 17, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient stay for hernia surgery.
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary, as the enrollee has an unusual hernia. The Plan denied your request. The Plan says the medical records do not show that this procedure must be completed in an inpatient hospital setting.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found there is no documentation provided necessitating the requested inpatient hospital stay.The review has determined that the record does not that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. The physician says the inpatient stay may not be required however, she will not know until surgery is performed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient stay for hernia surgery.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an outpatient C4-5 anterior cervical discectomy and fusion for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says there are multiple etiologies of the enrollee's chronic neck pain, and the demonstrated retrolithesis is minimal and not indicated for a cervical fusion.
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 the surgery. Our reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found the criteria for fusion is not met. There is no instability, fracture, or lesion. There are multiple levels of degenerative disc disease. There is no clear correlation between the MRI and the exam. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve an outpatient C4-5 anterior cervical discectomy and fusion for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device (22869).
You asked the Plan to pre-approve the Vertiflex device. You say that the device is medically necessary for treatment of the member's condition. The Plan denied your request. The Plan says medical studies have not proven the device is helpful in the treatment of the member's condition.
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 the Vertiflex device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental and more researched is needed to show its safety and efficacy. 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 Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device (22869).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services (90837) provided on August 28, 2019 to October 29, 2019 by out of network provider.
You asked the Plan to pay for the outpatient mental health services. You say that you were told the provider is in-network. The Plan denied your request. The Plan says the provider is out of network and the services were not emergent or preauthorized.
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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the outpatient mental health services (90837) provided on August 28, 2019 to October 29, 2019 by out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone graft in preparation for a dental implant (21210).
You asked the Plan to pre-approve a bone graft in preparation for a dental implant. You say that the service is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 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 a bone graft in preparation for a dental implant. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found the placement of a bone graft for the placement of an implant in area #14 would be considered the replacement of a structure (bone) directly supporting the tooth (implant). This is a service that is not covered according to the rules of Medicare coverage. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a bone graft in preparation for a dental implant have not been met. Therefore, we decided that the Plan does not have to pre-approve a bone graft in preparation for a dental implant (21210).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zarxio.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested drug is subject to step therapy.
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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found there is no evidence of a trial and failure of Neupogen or Nivestym. The documentation does not support that Neupogen (filgrastim), Nivestym (filgrastim-aafi) would likely be less effective, and/or would likely have adverse effects for the enrollee 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 the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Zarxio.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta 32mg injections.
You asked the Plan to pre-approve the Zilretta. You say that the injection is medically necessary because the enrollee cannot use his arm. The Plan denied your request. The Plan says the requested drug is not indicated for osteoarthritis of the shoulder.
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 the Zilretta. Our reviewer says that coverage criteria has not been met. Our physician reviewer found Zilretta injection is not medically appropriate for arthritis of the shoulder. The efficacy and safety of Zilretta for management of osteoarthritis pain of the shoulder has not been evaluated by the FDA and is not otherwise supported in medical literature. 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 Zilretta have not been met. Therefore, we decided that the Plan does not have to pre-approve Zilretta 32mg injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on September 6, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not be charged a copayment for the physician's error. The Plan denied your request. The Plan says you have been charged 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 $45 copayment for an in-network specialist office visit. You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record shows diagnoses of epiretinal membrane (ERM) of the left eye and cataracts.
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 specialist office visit provided on September 6, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance supplies provided on September 14, 2019.
You asked the Plan to pay for the ambulance supplies. You say that because of your medical condition the ambulance service was medically necessary. The Plan denied your request. The Plan says ambulance supplies are not separately payable.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We looked at the file and Medicare rules. Ambulance supplies are included in the ambulance fee. You are not responsible for this cost. Based on this information, we decided that Medicare rules for coverage of the ambulance supplies have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance supplies provided on September 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-referral-circle orthopedic specialist for the enrollee.
You asked the Plan to pre-approve the referral. You say that you are in the process of changing PCPs, and the current PCP will not write a referral. The Plan denied your request. The Plan says the services are available from providers in the Hallmark Health referral circle, and there is no evidence that seeing a provider within the referral circle would be detrimental to your health, or that it is medically necessary.
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 the referral. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee can be safely treated in-plan by an orthopaedist. There is no need for an out-of-plan referral. 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 referral have not been met. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-referral-circle orthopedic specialist for the enrollee.