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

We decided that the Plan does not have to pre-approve Stelara.

You asked the Plan to pre-approve Stelara. You say that you would like Stelara to be administered by your dermatologist approved for coverage. The Plan denied your request. The Plan says there is no medical necessity for you to receive the Stelara injection in the dermatology department. The Plan also says that you will need to pick up the medication from the pharmacy department to self-administer at home.

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 Stelara.

Benefits for Stelara 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cleaning (D1110), periodic oral evaluation (D0120),
intraoral x-ray (D0220) and unspecified preventative procedure (D1999) provided on January 5, 2021.

You asked the Plan to pay for the dental services. You say that you feel the Plan has not paid enough for these
services, and you know that you have a $1,000 benefit allowance so you do not understand why the Plan did
not pay the full amount. The Plan denied your request. The Plan says this claim was applied correctly because
you used 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.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested unspecified preventative
procedure is not among those covered under this benefit. Therefore, we decided that the Plan does not have to
pay for the unspecified preventative procedure (D1999) provided on January 5, 2021.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The Plan will pay up to the maximum allowable charge for a dental
service that is listed with a $0 copayment. However, if you use an out-of-network dentist, you will be
responsible for the full amount of the provider's charge that exceeds the Plan's allowable charge.

The out-of-network provider charged $293 for the cleaning, periodic oral evaluation and intraoral x-ray. The
Plan's total allowed amount for these three services is $105. The Plan has paid the full $105 allowed amount
for these services, leaving you with a $0 copayment on the allowed amount. This is the same amount the Plan
would pay for these services if they were received from an in-network provider. However, because you used an
out-of-network provider, you are responsible for the full amount of the provider's charge that exceeds the
Plan's allowable charge. This means that you are responsible for $188 ($293 - $105 = $188) for the covered
services. 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 pay an additional amount for the cleaning (D1110), periodic oral
evaluation (D0120) and intraoral x-ray (D0220) provided on January 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency ambulance transport
(A0427) provided on October 20, 2020.

You asked the Plan to waive the copayment for an emergency ambulance transport. You say that you want the
Plan to pay. The Plan denied your request. The Plan says the copayment was 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 $225
copayment for ambulance services.

You have been asked to pay a $225 copayment for an emergency ambulance transport. The service at issue
falls within the Ambulance services benefit category. This means that you have been asked to pay the correct
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for
an emergency ambulance transport (A0427) provided on October 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cardiac CT scan.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare does not cover screening for asymptomatic patients.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Despite multiple attempts by the plan, records were not able to be received for this case. Without records, it cannot be determined if the service is reasonable and necessary. Without the records available, it has to be assumed that the scan is for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve a cardiac CT scan.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 11, 2021.
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 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 rendered on January 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Euflexxa (J7323).
You asked the Plan to pre-approve Euflexxa. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says step therapy rules for Euflexxa have not been met because the enrollee has not tried Orthovisc and Monovisc.
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 Euflexxa. Our reviewer says that the requested drug is not medically necessary. Our physician reviewer found that the Plan requires a trial of drugs Orthovisc and Monovisc before they will approve the requested drug. Based on the medical documentation provided for review, the enrollee has not tried and failed the required drugs of Orthovisc and Monovisc. The required drugs would not likely be less effective and/or likely to have adverse effects for the enrollee, based on documentation provided for review. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Euflexxa (J7323).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0482) provided on August 5, 2020.
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration as you continue to do your part in providing timely testing during the toxicology pandemic. 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 find that CPT code G0482 is not supported in the record. Specifically, this claim was billed with a laboratory POS code while the record indicates that the member's face-to-face service was rendered in an office setting. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0482) provided on August 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automatic blood pressure monitor (A4670).
You asked the Plan to pre-approve an automatic blood pressure monitor. You say that you need this because you have high blood pressure and diabetes. The Plan denied your request. The Plan says this is not covered for your condition.
The Plan must follow Medicare rules. Medicare rules say that Ambulatory Blood Pressure Monitoring (ABPM) is reasonable and necessary for beneficiaries with suspected white coat hypertension or suspected masked hypertension as defined in the NCD.
We looked at the file and Medicare rules. The submitted medical records do not show that you have suspected white coat hypertension or suspected masked hypertension as defined in the NCD. Based on this information, we decided that Medicare rules for coverage of an automatic blood pressure monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor (A4670).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 11, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says with limited exceptions, the enrollee must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available, out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers.
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 physician's 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 physician's services provided on September 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, first intraoral periapical x-ray, each additional intraoral periapical x-ray, bitewings, and periodontal maintenance provided on March 17, 2021 by an OON provider.

You asked the Plan to pay for the periodic oral evaluation, first intraoral periapical x-ray, each additional intraoral periapical x-ray, bitewings, and periodontal maintenance. You say that you believe these services should be covered. The Plan denied your request. The Plan says these services were rendered by an OON 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. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, first intraoral periapical x-ray, each additional intraoral periapical x-ray, bitewings, and periodontal maintenance provided on March 17, 2021 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on January 5, 2021.
You asked the Plan to waive the copayment for the eye exam. You say that this was supposed to be your one eye exam a year not a regular appointment. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan contract says that enrollees must pay $10 for Medicare-covered physician services. Covered services include consultation, diagnosis, and treatment by a specialist.
You have been asked to pay a $10 copayment for the eye exam. The eye exam falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that a medical eye exam was performed for diagnostic purposes. 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 eye exam provided on January 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic comprehensive evaluation provided on September 29, 2020.

You asked the Plan to pay for the services provided. You say that this test was deemed medically necessary. The Plan denied your request. The Plan says predictive screening testing is not a Medicare benefit.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file, and Medicare rules. Genetic testing procedures submitted under CPT code 81443 are unlikely to impact therapeutic decision-making in the clinical management of the enrollee 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 diagnostic comprehensive evaluation provided on September 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve service dog support items.
You asked the Plan to pre-approve the service dog support items. You say that you would like reconsideration because your service dog is necessary to alert you to sounds as you are hearing impaired. The Plan denied your request. The Plan says you do not meet criteria because your service dog is not ADA certified.
The Plan must follow Medicare rules. Medicare does not cover service dog supplies; therefore, the Plan's rules apply in this case. The Plan rules state that this allowance is for the purchase of predetermined supplies for a qualifying ADA service dog. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service dog support items have not been met. Specifically, the record indicates that your primary care physician does not have documentation that your service dog is ADA certified. There is insufficient evidence in the file to show that your dog is a qualifying ADA service dog. Therefore, we decided that the Plan does not have to pre-approve service dog support items.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve scaling and root planing (D4341) for all 4 quadrants.
You asked the Plan to pre-approve the dental services. You say that these services should be covered. The Plan denied your request. The Plan says scaling and root planing are not listed as covered 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, 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 scaling and root planing (D4341) for all 4 quadrants.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on December 22, 2020 by an out of network (OON) provider.

You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. You say that your lab performed all the tests that were ordered by the referring physician. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that prior authorization was not obtained by the member's primary care physician or a participating provider.

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 lab work provided on December 22, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services coded 99152 provided on
November 18, 2020.
You asked the Plan to pay for the moderate sedation services. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the
documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 99152 is moderate sedation services provided by the
same physician or other qualified health care professional performing the diagnostic or therapeutic service that
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age
5 years or older.
We find that CPT code 99152 is not supported in the medical record. Specifically, the documentation submitted
does not indicate the presence of an independent trained observer to assist in the monitoring of the patient's
level of consciousness and physiological status; therefore, the billed service cannot be verified. Based on this
information, we decided that Medicare rules for coverage of the moderate sedation services have not been met.
Therefore, we decided that the Plan does not have to pay for the moderate sedation services coded 99152
provided on November 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the nuclear medicine study provided December 22, 2020.

You asked the Plan to waive the copayment for the nuclear medicine study. You say that you were told a different copayment. The Plan denied your request. The Plan says the copayment has processed correctly in this case.

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 $125 copayment for Advanced Imaging Services provided in an outpatient hospital facility. 

You have been asked to pay a $125 copayment for the nuclear medicine study. This service falls within the Advanced Imaging Services provided in an outpatient hospital facility 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 nuclear medicine study provided December 22, 2020.
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 the enrollee would benefit from an IRF admission.
The Plan denied your request. The Plan says the enrollee's needs can be provided at a lower level of care.

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 there are no complex nursing or rehabilitation needs. The patient does not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. The patient does require physical and occupational therapy but there is no
documented need for an intensive rehabilitation program. Medically necessary services can be provided in a
different level of care. There is not a reasonable expectation that this patient 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), fixed prosthodontic procedure (D6999), and drugs or medicaments dispensed in the office for home use (D9630) provided on May 6, 2020, and May 18, 2020 by an OON provider.

You asked the Plan to pay for the first intraoral periapical x-ray, fixed prosthodontic procedure, and drugs or medicaments. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services are not covered benefits under your dental 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 pay for the first intraoral periapical x-ray (D0220), fixed prosthodontic procedure (D6999), and drugs or medicaments dispensed in the office for home use (D9630) provided on May 6, 2020, and May 18, 2020 by an OON provider.