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

We decided that the Plan has to pay for the periodic oral evaluation and prophylaxis provided on February 8, 2021.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that the provider did not tell you that they did not participate with Medicare prior to rendering the services. The Plan denied your request. The Plan says that the treating provider has opted out of Original Medicare.
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 rules also say that the health plan must provide you with a clear and accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under your plan contract including applicable conditions and limitations and any other conditions associated with the use or receipt of the benefits. The Plan denied these services for being rendered by a Medicare opt out provider. The 2021 EOC does not clearly mention that services rendered by a Medicare opt out provider will not be covered. The 2021 EOC covers oral exams and routine cleanings, and you reasonably believed these services would be covered. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the periodic oral evaluation and prophylaxis have been met. Therefore, we decided that the Plan has to pay for the periodic oral evaluation and prophylaxis provided on February 8, 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 pay for the intraoral x-rays (D0220, D0230), unspecified preventative procedure (D1999) and periodontal maintenance (D4910) provided on January 27, 2021.
You asked the Plan to pay for the dental services. You say that you were told this provider was in-network and these services would be covered. The Plan denied your request. The Plan says they have re-processed the claim and provided a one-time exception for the bitewing x-rays. However, the other services are not covered by your dental benefit, regardless of who provides the care.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral x-rays (D0220, D0230), unspecified preventative procedure (D1999) and periodontal maintenance (D4910) provided on January 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Tradjenta.

You asked the Plan to pre-approve Tradjenta. You say that the requested treatment is a necessity for the enrollee's care. The Plan denied your request. The Plan says rules for self-administered drugs have not been met.

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 treatment with Tradjenta.

Benefits for Tradjenta 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Zilretta (J3304).

You asked the Plan to pre-approve Zilretta. You say that the enrollee has trialed Depo-medrol. The Plan denied your request. The Plan says step therapy rules have not been met for the requested drug because Dexamethasone and Triamcinolone have not been tried.

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 Zilretta. Our reviewer says that the requested treatment is not medically necessary. Our physician reviewer found that the use of Zilretta is permitted only after failure of the 3 preferred intra-articular steroids. The enrollee has only trialed Depo-medrol.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Zilretta (J3304).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray provided on February 1, 2021.
You asked the Plan to waive the copayment for the x-ray. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received an x-ray on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
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 $150 copayment for x-rays performed in an outpatient hospital setting. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an x-ray performed in an outpatient hospital setting on February 1, 2021. You have been asked to pay a $78.40 copayment for the x-ray, which is less than the contracted $150 copayment amount. The x-ray falls within the Outpatient diagnostic tests 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 x-ray provided on February 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an alignable system feature for a prosthetic leg (L5910)
for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says a replacement alignable system exceeds medical need and is not reasonable and
necessary for the approved replacement socket.
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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the enrollee was approved for an L5910 on 12/20 and the physician documentation does not indicate a
need for a replacement L5910. Furthermore, the documentation does not reveal damage to the prior L5910.
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 pre-approve an alignable system feature for a prosthetic leg (L5910) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and an intraoral periapical
radiographic image (D0220) provided on November 25, 2020.
You asked the Plan to pay for a limited oral evaluation, and an intraoral periapical radiographic image. You say
that you want the Plan to pay for these services. The Plan denied your request. The Plan says you are not
covered for these services when seen by an out-of-network provider.
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 a limited oral evaluation, and an intraoral periapical radiographic image have not been met.
Specifically, services were provided by an out-of-network provider. The Plan has contracted providers available to provide these services. 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 limited oral evaluation (D0140), and an intraoral periapical radiographic image (D0220) provided on November 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on October 28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the physician services provided on October 28, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays (D0274) and dental cleaning (D1110) provided on March 10, 2021, by an out-of-network provider.

You asked the Plan to pay for the dental services. You say that you wanted to see your usual dentist, because you knew and felt comfortable with their COVID protocols. The Plan denied your request. The Plan says out-of-network dental care 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, items or services received out-of-network are not among those covered under this benefit.

Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays (D0274) and dental cleaning (D1110) provided on March 10, 2021, by an out-of-network provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the WATS 3D testing provided on September 21, 2020.

You asked the Plan to pay for the services provided. You say that the ordering physician made a professional
determination of medical necessity. The Plan denied your request. The Plan says that medical literature does
not support the clinical utility of the testing.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The plan follows these rules.

The enrollee was referred for the services provided by a contract provider. The file does not show that the plan
provided notice that the services provided would not be covered. Under Medicare rules, this means the services
provided is considered approved by the plan. Furthermore, the American Society of Gastrointestinal Endoscopy
suggests using WATS-3D (brush) biopsy testing in patients with known or suspected Barrett's Esophagus.
Therefore, we decided that the Plan has to pay for the WATS 3D testing provided on September 21, 2020.

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 pay for the hearing aids and related services (V5261, V5266, V5267,
V5299, S9999) received January 18, 2021 from a non-Plan hearing vendor.
You asked the Plan to pay for the hearing aids and related services. You say that you were not informed that
you needed to use a Plan hearing network vendor in 2021. The Plan denied your request. The Plan says hearing
aids and related services purchased outside of the Plan's hearing vendor network are not covered.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only purchased through the Plan's hearing vendor network.
We looked at the file, and the Plan's rules. You purchased the hearing aids and related services outside of the
Plan's hearing vendor network. Based on this information, we decided that the Plan's rules for coverage of the
hearing aids and related services have not been met. Therefore, we decided that the Plan does not have to pay
for the hearing aids and related services (V5261, V5266, V5267, V5299, S9999) received January 18, 2021
from a non-Plan hearing vendor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for retainer crowns (D6740 x2), pontic (D6245), and an unspecified preventive procedure (D1999) provided on February 4, 2021.
You asked the Plan to pay for retainer crowns, pontic, and an unspecified preventive procedure. You say that the services were medically necessary. The Plan denied your request. The Plan says the services at issue are not covered benefits.
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 retainer crowns (D6740 x2), pontic (D6245), and an unspecified preventive procedure (D1999) provided on February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Shingles vaccine provided on February 1, 2021.

You asked the Plan to pay for the Shingles vaccine. You say that your guidebook states shingles vaccines are covered 100%. The Plan denied your request. The Plan says the Shingles vaccine is not covered under your Medicare Part B drug benefit.

The Plan does not cover a Shingles vaccine. The Shingles vaccine is a Part D drug and does not meet Medicare Part B coverage rules. Therefore, we decided that the Plan does not have to pay for the Shingles vaccine provided on February 1, 2021.

Benefits for the Shingles vaccine 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has refused various and treatments during the current inpatient skilled nursing facility stay.
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 pre-approve the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing or skilled therapy needs. You are not fully partaking in care, and are noted by the facility provider to have reached maximum potential from treatment. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point are considered custodial and, as a practical matter, can be provided at a lower level of care. 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 pre-approve continued admission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis.
You asked the Plan to pre-approve CT scan of the abdomen and pelvis. You say that this request is medically necessary. The Plan denied your request. The Plan says they did not have enough information to approve this decision.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically 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 pre-approve CT scan of the abdomen and pelvis. Our reviewer says that the request is not medically reasonable and necessary in this case. Our physician reviewer found that you are a 69-year-old female who is status post septic shock due to a perinephric abscess. You have evidence of a fistulous tract in the descending colon. You have also had a recent Urology evaluation that was normal. The review indicates that there is no clinical rationale for the requested CT scan. The requested CT scan is not medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CT scan of the abdomen and pelvis have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 20, 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.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 20, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from October 21, 2020, to November 19, 2020.

You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition no longer required daily skilled services at an inpatient SNF level of care.

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 skilled nursing services. 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from October 21, 2020, to November 19, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided the Plan does not have to pay for outpatient mental health services provided on January 14,2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization.
Medicare rules say that plans can require prior authorization. The Plan contract states the outpatient mental health care may require prior authorization. The Plan did not pre-approve this service. Therefore, we decided the Plan does not have to pay for outpatient mental health services provided to the enrollee on January 14,2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the positron emission tomography (PET) scan rendered on December 3, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code. We looked at the file and Medicare rules. The file shows that the claim was not billed with a valid diagnosis code.
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 pay for the positron emission tomography (PET) scan rendered on December 3, 2020.