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

We decided that the Plan does not have to pre-approve Prolia (Denosumab).
You asked the Plan to pre-approve the Prolia. You say that the enrollee has failed bisphosphonate therapy with Alendronate which the enrollee has taken for the past 3 years. You also say that your recommendation is that Prolia is indicated for the treatment of the enrollee's osteoporosis. The Plan denied your request. The Plan says the provided documentation does not show that the enrollee has either a history of osteoporosis-related fracture or has failed or has a contraindication to Zoledronic Acid.
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 Prolia. Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has not tried and failed the required drug, Zoledronic Acid. Our reviewer found that the documentation does not support that Zoledronic Acid would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer also found that the enrollee does not have a history of osteoporotic fracture.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (Denosumab).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for naturopathic services provided from December 18, 2019 to December 26, 2019.
You asked the Plan to pay for naturopathic services. You say that this should be covered because your primary care physician referred you for this service. The Plan denied your request. The Plan says these services are not covered under Medicare rules.
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services. The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have to pay for naturopathic services provided from December 18, 2019 to December 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided from June 3, 2019 to September 30, 2019.
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 psychotherapy services provided from June 3, 2019 to September 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says services rendered by non-participating providers require prior authorization.
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 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 services provided to the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture (D5110) and resin-based composite (D2394) provided on January 29, 2020.
You asked the Plan to pay for the complete maxillary denture and resin-based composite. You say that you feel that you were overcharged for extractions you received earlier in January. You also say that you need the dentures. The Plan denied your request. The Plan says this service has exceeded the $2,000 annual maximum payout for dental services for plan year 2020.
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 Plan offers a $2,000 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit on January 3, 2020 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the complete maxillary denture (D5110) and resin-based composite (D2394) provided on January 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the hemiarthroplasty services coded 27125 provided on December 3, 2019.
You asked the Plan to pay for the hemiarthroplasty 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 27125 is hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty). We find that CPT code 27125 is not supported in the medical record. Specifically, the documentation submitted indicates that open treatment of femoral fracture, proximal end, neck, internal fixation or prosthetic replacement was performed. There is a more appropriate CPT code that should be billed for the services provided. Based on this information, we decided that Medicare rules for coverage of the hemiarthroplasty services have not been met. Therefore, we decided that the Plan does not have to pay for the hemiarthroplasty services coded 27125 provided on December 3, 2019.
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 the shower chair was not requested for hygiene but because you recently experienced a fall. You say that if you fall again there is the danger of injuring yourself and having another fracture. The Plan denied your request. The Plan says this item is not a covered benefit.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient clinic services provided to the enrollee.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the services were not authorized in compliance with the plan's authorization procedures.
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 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 outpatient clinic services provided to the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.
You asked the Plan to pre-approve a power wheelchair. You say that your guide dog is not trained to pull a
manual wheelchair. The Plan denied your request. The Plan says your needs can be sufficiently resolved by a
manual wheelchair.
The Plan follows Medicare rules. Medicare rules say that power mobility devices are only covered under
certain medical indications.
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 power wheelchair. Our physician
reviewer found that a power mobility evaluation notes that you have macular degeneration and cataracts. The
form notes that you do not demonstrate the ability to operate the PMD safely in the home due to vision deficits.
You were noted to be able to resolve your mobility deficits with a manual wheelchair. Therefore, the requested
wheelchair is not medically reasonable and 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 a power wheelchair have not been met. Therefore, we decided that the Plan does
not have to pre-approve a power wheelchair.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance transport.
You asked the Plan to waive the copay for the ambulance transport. The Plan denied your request. The Plan
says that the claim processed according to your plan benefits.
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 $350
copay for per one way trip for emergency and non-emergency ambulance services.
You have been asked to pay a $350 copay for the ambulance transport. The ambulance transport falls within
the one way trip for emergency and non-emergency 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 copay for the ambulance transport.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on May 8, 2019.
You asked the Plan to pay for the physician's services. You say that you had a tummy tuck on May 8, 2019 and
during the surgery they found a hernia. You say that a doctor cannot leave the hernia and it is his obligation to
remove the hernia. The Plan denied your request. The Plan says you must receive care from in-network
providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service
area or if the care cannot be provided with an in-network provider, which requires prior authorization from the
plan.
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
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 physician's services provided on May 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal guard (D9944) provided on January 7, 2020.
You asked the Plan to pay for the dental item. You say that you received a pre-authorization for the dental item on December 17, 2019. You say that you were advised that due to your change in insurance plans, the dental coverage had changed too. You also say that you were not able to look at a hard copy of the Evidence of Coverage until well into January. The Plan denied your request. The Plan says the occlusal guard is not listed as a covered dental item.
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 occlusal guard is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the occlusal guard (D9944) provided on January 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 2, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says nonemergent,
non-urgent services with out-of-network providers require prior authorization.
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 physician's services provided on December 2, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forsubsequent hospital care (CPT Code 99232) provided to the enrollee from November 23, 2019 through November 24, 2019.You asked the Plan to pay forthe services. You say that the claim should be paid.The Plan denied your request. The Plan says according to CMS Policy, separate payment is not allowed for Evaluation and Management services reported during the postoperative period with modifier 24 without sufficient indication that the visit is unrelated to the surgery. The Plan states Modifier 24 is intended for use with services that are absolutely unrelated to the surgery; it is not intended to be used for the medical management of a patient by the surgeon following surgery.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. The billed service, 99232, was bundled as part of the global surgical fee because it was reported within 90 days of the major surgical procedure, 43840, per CMS Policy.Therefore, we decided that the Plan does not have to pay forsubsequent hospital care (CPT Code 99232) provided to the enrollee from November 23, 2019 through November 24, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvedrugs provided during an outpatient hospital stay on November 18, 2019.You asked the Plan to pre-approvethe drugs provided during your emergency room visit. You say that you are asking that the plan reconsider your liability for the drugs in dispute, as you only receive a pension as your income. You say that you owe so many bills and need help. You say that you have to pay copayments for medicine from your doctor. You say that the plan pay for the drugs you were provided during your outpatient hospital visit.The Plan denied your request. The Plan says the hospital can billyou for self-administered drugs that aren't covered by Medicare Part B while in a hospital outpatient setting.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-approvedrugs provided during an outpatient hospital stay on November 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation and topical application of fluoride varnish provided on December 16, 2019.You asked the Plan to pay for the comprehensive periodontal evaluation and topical application of fluoride varnish. You say that you have a semiannual dental checkup with x-rays once a year, cleaning each time, fluoride treatment, and examination of teeth. You also say that these services were preventive care.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 comprehensive periodontal evaluation and topical application of fluoride varnish provided on December 16, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided on September 9, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient services were medically necessary.The Plan denied your request. The Plan says that the documentation does not support that the criteria for inpatient payment are met in this case.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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented to a non-participating hospital reporting left sided chest discomfort. Emergency department evaluation noted a new bundle branch block on an electrocardiogram, normal blood troponin level, and an elevated blood pressure reading. In the emergency department, the enrollee was evaluated by the cardiologist, had a bedside echocardiogram, and was given intravenous and sublingual medication to lower her blood pressure. The provider documented a plan for ongoing admission for ongoingtreatment of hypertensive urgency and further cardiac work-up. At the time this was determined, the enrollee had improved symptoms and vital signs. Care plan included oral anti-hypertensive medications with as needed supplementation intravenous medication, serial laboratory studies, and a cardiac stress test. The medical records provided indicate that the admitting physician expected the enrollee's admission to span two midnights.Inpatient hospital care was appropriate on 9/9/19 as the enrollee was notedto have an escalation of pain and blood pressure and underwent a non-emergent cardiac catheterization on this date.  As such, inpatient care starting on 9/9/19 is considered medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided on September 9, 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 group 1 power scooter (K0800).You asked the Plan to pre-approve a power scooter. You say that you would rather have a power scooter than a wheelchair because it would be easier to fit in your car.The Plan denied your request. The Plan says the approved power wheelchair is appropriate for your needs.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The rules also say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The record shows that the Plan has approved a group 2 power wheelchair, which would serve the same purpose as the requested group 1 power scooter. The reasons given for why you need a group 1 power scooter are for use outside the home. Although this item may be helpful, Medicare does not cover equipment for use outside the home.Therefore, we decided that the Plan does not have to pre-approve a group 1 power scooter (K0800).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee from April 6, 2017 through April 30, 2017, by a non-Medicare provider.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services were not authorized because this provider is non-certified by Medicare as a provider. The Plan states the member's primary care physician (PCP) did not refer for services.
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 services are not authorized because you are not certified by Medicare as a provider, do not work with the Plan, and the member self-directed for services. The member's PCP did not refer for services. The health plan requires utilization of Medicare-certified network providers, and requires authorization for non-urgent services. No urgent or emergency situation, has been documented. There is no network deficiency for these services and alternate network providers were found. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee from April 6, 2017 through April 30, 2017, by a non-Medicare provider.