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

We decided that the Plan does not have to pay for the complete series of intraoral x-rays provided on August
18, 2020.

You asked the Plan to pay for the complete series of intraoral x-rays. You say that you assumed that all x-rays
were covered by your insurance. You also say that you were not advised that you would be responsible for
additional x-rays. The Plan denied your request. The Plan says this service 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, the requested items or services are not
among those covered under this benefit. Your Plan only provides coverage for one set of bitewing x-rays per
calendar year. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral xrays
provided on August 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve HYALGAN.
You asked the Plan to pre-approve HYALGAN. The Plan denied your request. The Plan says the enrollee has
not met the step therapy requirements.
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 HYALGAN. Our reviewer says that
HYALGAN is not medically reasonable and necessary for the enrollee in this case. Our physician reviewer
found that the health plan requires that other forms of hyaluronic acid injections be used. There is no evidence
that the enrollee is allergic to or intolerant of Orthovisc and Monovisc. There is no evidence that the enrollee
has tried and not responded to these other forms of hyaluronic acid injections. There is no documentation as to
why these other forms of hyaluronic acid would not be expected to be safe and effective for the enrollee.
Therefore, the requested HYALGAN is not shown to be currently medically necessary and 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 HYALGAN have not been met. Therefore, we decided that the Plan does not
have to pre-approve HYALGAN.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing facility (SNF) care provided from May 29, 2020 to July 31, 2020.You asked the Plan to pay forthe SNF care. You say that the SNF care provided from May 29, 2020 to July 31, 2020 was medically necessary.The Plan denied your request. The Plan says the enrollee did not meet criteria for the provided SNF care from May 29, 2020 to July 31, 2020.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physicianreviewer found the enrollee is with a history of coronary artery disease, right hip fracture and open reduction internal fixation (ORIF), permanent atrial fibrillation (status post pacemaker implant), chronic diastolic heart failure, hypertension, hyperlipidemia, GERD, restless 
leg syndrome, and stroke. From a nursing perspective, the enrollee received oral medications.  The enrollee had stable vital signs. She was treated for pain with effect. Regarding rehabilitation services, the enrollee received physical therapy, speech therapy and occupational therapy in the SNF. By the dates in question, the enrollee was at a moderate assist level to dependent level with functional mobility. The enrollee required varying assist with activities of daily living.Thereare no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF care have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing facility (SNF) care provided from May 29, 2020 to July 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveproton beam radiation therapy.You asked the Plan to pre-approvethe requested services. The Plan denied your request. The Plan says the requested service is not the standard of care for prostate cancer.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 requested services. Ourphysician reviewer found that there is no clear evidence that proton beam therapy for prostate cancer offers any clinical advantage over other forms of definitive radiation therapy. Clinical trials are necessary to establish a possible advantage ofthis expensive therapy. Proton therapy would exceed the needs for this enrollee. Therefore, the requested services are not medically reasonable or 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 the requested services have not been met.Therefore, we decided that the Plan does not have to pre-approveproton beam radiation therapy.
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 4, 2020, by an in-network provider.
You asked the Plan to waive the copayment for the specialist office visit. You say that you are requesting reimbursement of services rendered. You state that ever since the surgery, you have had trouble swallowing and have even choked on your food. The Plan denied your request. The Plan says you are appealing your cost-share responsibility for the services you received. The Plan states they are addressing your dissatisfaction with the services you have received.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received the specialist office services provided on September 4, 2020, by an in-network provider. You were asked to pay a $35 copayment for the specialist services. Your 2020 EOC states that enrollees must pay a $35 copayment for in-network specialist 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 waive the copayment for the specialist office visit provided on September 4, 2020, by an in-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe preventive procedure (D1999) provided on May 14, 2020.You asked the Plan to pay forthe preventive procedure. You say that a Plan representative told you that this provider was in-network with the Plan. You also say that you are on a fixed income, and are unable to pay this bill.The Plan denied your request. The Plan says this service is not covered by the 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 forthe preventive procedure (D1999) provided on May 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on June 13, 2020.You asked the Plan to pay forthe ambulance services. The Plan denied your request. The Plan says the services were not medically necessary.The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. The documentation provided does not contain medical records from the non-contract provider for date of service June 13, 2020. The records provided are for date of service June 4, 2020. Without supporting documentation, it cannot be determined that Medicare coverage criteria have been met.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided on June 13, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveHydroxyz Hcl Tab 25mgYou asked the Plan to pre-approveHydroxyz Hcl Tab 25mg. You say that the item is medically necessary.The Plan denied your request. The Plan says the item is not covered under the enrollee's benefit plan.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-approveHydroxyz Hcl Tab 25mg
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the panoramic x-ray
(D0330) provided on September 10, 2020.

You asked the Plan to pay for the dental services. You say that you were advised that you had a $500
maximum for dental services. You also say that you paid cash for the services. The Plan denied your request.
The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be
made to providers who have opted out of Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the limited
oral evaluation (D0140) and the panoramic x-ray (D0330) provided on September 10, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy you received on
September 15, 2020.

You asked the Plan to waive the copayment. The Plan denied your request. The Plan says the claim was
processed 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 $200
copayment for each visit for outpatient surgery.

Review of the file shows that you had a diagnostic colonoscopy on September 15, 2020. You have been asked
to pay a $200 copayment for the colonoscopy. The colonoscopy falls within the outpatient surgery 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 diagnostic colonoscopy you received on
September 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea CT scan.You asked the Plan to pre-approvea CT scan. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.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 a CT scan. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has a history of prostate cancer. The enrollee has had weight loss and fatigue with abnormal laboratory studies and an abnormal CXR. There is no specific clinical rationale for the requested CT studies. The requests need further clarification as to blood work abnormalities, physical exam findings and chest x-ray results. Therefore, the enrollee does not meet criteria for the requested services.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 CT scan have not been met.Therefore, we decided that the Plan does not have to pre-approvea CT scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecompression stockings (A6530, A6549, E1399)You asked the Plan to pre-approvethe compression stockings. You say that this is medically necessary.The Plan denied your request. The Plan says the requested supplies are statutorily not covered by Medicare.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530, A6549, E1399 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approvecompression stockings (A6530, A6549, E1399)
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Superion interspinous spacer for the enrollee.
You asked the Plan to pre-approve the spacer. You say that this is medically necessary. The Plan denied your
request. The Plan says this is considered experimental and investigational.
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 spacer. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the device is experimental. More research is needed to show 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 spacer have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Superion interspinous spacer for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Metoprol Tar Tab 25mg.
You asked the Plan to pre-approve Metoprol Tar Tab 25mg. You say that the service is medically necessary.
The Plan denied your request. The Plan says Metoprol Tar Tab 25mg to be taken at home is not Medicare
covered under the Part A or B benefit.
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 Metoprol Tar Tab 25mg.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (36906, 37246, 37248) provided June 2,
2020.
You asked the Plan to pay for the surgical services. You say that these services were medically necessary. The
Plan denied your request. The Plan says the documentation does not support the billed services.
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 codes 36906, 37246, & 37248 are not supported in the medical record. Specifically, the
documentation provided does not support the billed CPT codes. There are certain types of improper coding that
physicians must avoid. Procedures should be reported with the most comprehensive CPT code that describes
the services performed. Physicians must avoid upcoding. A HCPCS/CPT code may be reported only if all
services described by that code have been performed. Based on this information, we decided that Medicare
rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have
to pay for surgical services (36906, 37246, 37248) provided June 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvesclerotherapy for treatment of spider veins (telangiectases).You asked the Plan to pre-approvesclerotherapy. You say that the requested service is medically necessary.The Plan denied your request. The Plan says rules for medical necessity have not been met.The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable.  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 sclerotherapy. Our reviewer says that the requested service is not medically necessary. Our reviewer found that the documentation supports classifying the procedure in question as cosmetic and does not support the medical necessity of the procedure in question.The enrollee is symptom-free after greater saphenous vein ablation and has no new pain in the leg.Nevertheless, the enrollee is interested in getting sclerotherapy for spider veins.Therefore, our reviewer considers the procedure to be cosmetic in nature and that the documentation does not support the medical necessity of the procedure.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sclerotherapy have not been met.Therefore, we decided that the Plan does not have to pre-approvesclerotherapy for treatment of spider veins (telangiectases)
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent nursing facility care and services provided on April 16, 2020, by an OON provider.You asked the Plan to pay forthe subsequent nursing facility care and services. You say that the facility is responsible for getting the authorizations because the doctors are there to treat the patients. You also say that the doctors are unaware of the insurance the enrollees have, and if they need an authorization or referral.The Plan denied your request. The Plan says these services were rendered by a non-contracted provider. The Plan also says that prior authorization was not 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 forthe subsequent nursing facility care and services provided on April 16, 2020,by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe moderate sedation services rendered on May 11, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 99152 is not supported.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 by physician also performing a procedure, patient 5 years of age or older, first 15 minutes.We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of an independent trained observer to assist in monitoring the patient's level of consciousness or physiological status, first 15 minutes. 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 forthe moderate sedation services rendered on May 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea transthoracic echocardiogram (TTE).You asked the Plan to pre-approvethe TTE. You say that it is felt that this imaging is needed to assess the enrollee's condition.The Plan denied your request. The Plan says the enrollee has no new symptoms and has been stable. This testing is not warranted at this time.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 TTE. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the records, the patient has already hadan echocardiogram in July 2016 with no significant abnormalities and has no documented cardiac symptoms or objective cardiac abnormalities on subsequent physical exam or electrocardiogram.In this circumstance of clinical stability, the records do not support the medical necessity for a repeat echocardiogram.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 TTE have not been met.Therefore, we decided that the Plan does not have to pre-approvea transthoracic echocardiogram (TTE)