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

We decided that the Plan does not have to pre-approve an occlusal guard - hard appliance, full arch (D9944).

You asked the Plan to pre-approve a mouth guard. You say that the mouth guard is medically necessary, and you cannot afford it. The Plan denied your request. The Plan says this service is not covered under your 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 pre-approve an occlusal guard - hard appliance, full arch (D9944).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a spinal canal injection provided on February 3, 2021.
You asked the Plan to waive the copayment for a spinal canal injection. You say that you disagree with the $200 charge because you never had to pay it in the past. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received a spinal canal injection at an outpatient hospital facility on February 3, 2021. A spinal canal injection is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $200 copayment.
You have been asked to pay a $200 copayment for a spinal canal injection. A spinal canal injection falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 a spinal canal injection provided on February 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a blood pressure monitor (E1399).
You asked the Plan to pre-approve a blood pressure monitor. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says this is considered a convenience item and not covered.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pre-approve a blood pressure monitor (E1399).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Keytruda.

You asked the Plan to pre-approve Keytruda; Injection, pembrolizumab, 1 mg (J9271). You say that this drug is medically necessary for the enrollee. The Plan denied your request. The Plan says that first line therapy Pembrolizumab as single agent therapy is considered category 2B, therefore investigational.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Keytruda; Injection, pembrolizumab, 1 mg (J9271). Our reviewer says that the drug is medically reasonable and necessary. Our physician reviewer found although 2b, recommendation of National Comprehensive Cancer Network (NCCN) per package insert allowed for stage IV disease with no actionable mutations and PDL1>1. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda; Injection, pembrolizumab, 1 mg (J9271) have been met. Therefore, we decided that the Plan has to pre-approve Keytruda.

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 therapeutic continuous glucose monitor and supplies.
You asked the Plan to pre-approve a therapeutic continuous glucose monitor and supplies. You say that this request is medically necessary. The Plan denied your request. The Plan says the criteria for a continuous glucose monitor have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on January 21, 2021.

You asked the Plan to pay for the office visit. You say that authorization for the service was not obtained but the medical records prove the service was medically necessary. You say that the claim should be considered for payment. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not approved in advance.

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 for the office visit provided by an out-of-network provider on January 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral complete x-ray series (D0210) provided on October 6, 2020, and the resin-based fillings (D2392) provided on October 16, 2020.

You asked the Plan to pay for the x-rays and fillings. You say that you believed this provider was in-network as you found their information through the Plan's website. The Plan denied your request. The Plan says they have made an exception in this case and re-processed the covered services at the in-network rate. However, the complete x-ray series is not covered by your dental benefit, and only one filling per year may be covered. The Plan has provided documentation that they have agreed to cover one of the resin-based fillings (D2331) provided on October 16, 2020, as requested. The remaining fillings exceed the benefit maximum.

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 or are requested in a frequency that exceeds what is covered by the benefit. Therefore, we decided that the Plan does not have to pay for the intraoral complete x-ray series (D0210) provided on October 6, 2020, and the resin-based fillings (D2392) provided on October 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extraction, erupted tooth requiring removal of bone
and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) performed by an
oral surgeon.
You asked the Plan to pre-approve a tooth extraction performed by an oral surgeon. You say that you need your
tooth extraction performed by an oral surgeon due to a heart condition. The Plan denied your request. The Plan
says dental services are only covered by the Plan when performed by a participating general dentist.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a tooth
extraction when performed by a participating general dentist.
We looked at the file and Medicare rules. In this case you are requesting a tooth extraction to be performed by
an oral surgeon. The Plan will only cover dental services when performed by a participating general dentist.
Based on this information, we decided that the Plan's rules for coverage of a tooth extraction performed by an
oral surgeon have not been met. Therefore, we decided that the Plan does not have to pre-approve an
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of
mucoperiosteal flap if indicated (D7210) performed by an oral surgeon.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta (triamcinolone acetonide ER) (CPT code J3304), for the enrollee.

You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied your request. The Plan says there is no evidence the enrollee failed treatment with Kenalog and why step therapy would not be effective.

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 medication. Our physician reviewer found the Plan requires a trial of drug Kenalog before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee.

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 medication have not been met. Therefore, we decided that the Plan does not have to pre-approve Zilretta (triamcinolone acetonide ER) (CPT code J3304), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray, core buildup, including any pins when required, and crown provided on June 11, 2020 by a Medicare opt out provider.

You asked the Plan to pay for the first intraoral periapical x-ray, core buildup, and crown. You say that you would like these services to be covered. The Plan denied your request. The Plan says services performed by a privately contracted provider are not covered. The Plan also says that you did not contact the Plan prior to receiving the 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 covered when they are rendered by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray, core buildup, including any pins when required, and crown provided on June 11, 2020 by a Medicare opt out provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home-delivered meals.

You asked the Plan to pre-approve home-delivered meals. You say that the services are necessary. The Plan denied your request. The Plan says home-delivered meals are not covered under any conditions.

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. Based on this information, we decided that Medicare rules for coverage of home-delivered meals have not been met. Therefore, we decided that the Plan does not have to pre-approve home-delivered meals.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a nuclear medicine study of the liver and does not have to waive the coinsurance for a Medicare Part B drug provided on March 4, 2021.
You asked the Plan to waive the copayment for a nuclear medicine study of the liver and to waive the coinsurance for a Medicare Part B drug. You say that you received the wrong test and should not be responsible for the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $165
copayment for diagnostic radiology services. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B drugs. You received a nuclear medicine study of the liver on March 4, 2021. Therefore, you are responsible to pay the $165 copayment. You received a Medicare Part B drug on March 4, 2021. The total allowed amount is $115.55 and 20% of that is $23.11. The total amount you owe is: $188.11. You have been asked to pay the total amount of $188.11 for a nuclear medicine study of the liver and a Medicare Part B drug. A nuclear medicine study of the liver falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. A Medicare Part B drug falls within the Medicare Part B prescription drugs 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 a nuclear medicine study of the liver and does not have to waive the coinsurance for a Medicare Part B drug provided on March 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0425, A0427) received January 13, 2021.

You asked the Plan to waive the copayment for the ambulance transportation. You say that you should not have to pay the copayment because you were not given a choice about receiving ambulance services. The Plan denied your request. The Plan says the correct cost share applied to the claim.

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 $325 copayment for Medicare-covered ambulance services. 

You have been asked to pay a $325 copayment for the ambulance transportation. This service was a Medicare-covered ambulance service. 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 ambulance transportation (A0425, A0427) received January 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an office visit to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an office visit to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Freestyle Libre.
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 following information is lacking: diagnosis, testing frequency, insulin treatment, medical, history.
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 criteria requires that the patient use insulin multiple times per day, and adjusts insulin according to blood glucose levels. This criteria has not been met. 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 the Freestyle Libre.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for podiatry services provided on February 17, 2021.

You asked the Plan to waive the deductible for podiatry services. You say that you feel that the charges are too high for the service that was rendered. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible for podiatry services.

You received podiatry services on February 17, 2021. The record shows that you had only paid $73.26 toward the $750 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $84.

The item or service you asked the Plan to waive the deductible for falls within the benefit category podiatry services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for podiatry services. This cost sharing is a contractual obligation that had not been met at the time podiatry services were received on February 17, 2021. Therefore, we decided that the Plan does not have to waive the deductible for podiatry services provided on February 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve naturopathic services.

You asked the Plan to pre-approve naturopathic services. You say that there is no other solution to your shoulder pain. The Plan denied your request. The Plan says this is not covered.

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 pre-approve naturopathic services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Evenity injection (J3111).

You asked the Plan to pre-approve Evenity injection (J3111). You say that you want the enrollee to be treated with this drug. The Plan denied your request. The Plan says the enrollee has not tried and had an adverse reaction to oral and/or IV bisphosphonate therapy.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Evenity injection (J3111). Our reviewer says that the drug is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided the patient has not tried and failed the required drug(s). Based on the medical records provided there is a concern with regard to the use of an oral bisphosphonate due to a diagnosis of gastroesophageal reflux disease requiring daily treatment with a proton pump inhibitor but there is no indication that an intravenous bisphosphonate would likely be less effective and/or likely have adverse effects for the patient.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Evenity injection (J3111) have not been met. Therefore, we decided that the Plan does not have to pre-approve Evenity injection (J3111).