Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from an
admission to an LTACH and cannot be moved to a lower level of care The Plan denied your request. The Plan
says the Plan will continue to cover medically necessary acute and critical care at the current facility. The
enrollee does not have clinical conditions that cannot be appropriately treated in the current hospital, and there
are no issues for which an LTACH would offer a therapeutic advantage.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee is currently receiving acute care services, and these have not been denied
by the Plan. The medical record does not indicate that the enrollee requires services that are not currently
available but would be available at the LTACH facility. The elements of the coverage rules are not satisfied;
the requested services cannot be recommended.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient rehabilitation services provided
February 3, 2021 to February 20, 2021.
You asked the Plan to waive the copayment for the inpatient rehabilitation services. You say that the
copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied.
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 $275
per day copayment for days 1 through 6 for inpatient rehabilitation services.
You have been asked to pay a $275 per day copayment for days 1 through 6 for the inpatient rehabilitation
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 inpatient rehabilitation services provided
February 3, 2021 to February 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.
You asked the Plan to pre-approve facet joint injections. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that a second diagnostic facet procedure is considered medically reasonable and necessary when specific criteria are met. 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 facet joint injections. Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case, there is no percentage of relief reported from first diagnostic MBB provided. The criteria states that after the first diagnostic facet joint procedure, there must be a consistent positive response of at least 80% relief of primary (index) pain (with the duration of relief being consistent with the agent used. The review has determined that the enrollee does not meet the coverage criteria. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (17003) provided October 19, 2020.

You asked the Plan to pay for surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the number of units billed exceeds the number of units supported in the record.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. 

In this case, the MUE for CPT code 17003 is 13. The MAI value for this code is 2. You billed 14 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (17003) provided October 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to pre-approve an ultraviolet light therapy (UV Therapy) box for home use.

You asked the Plan to pre-approve a UV therapy box for home use. You say that your ability to use this device
in the home is medically necessary. The Plan denied your request. The Plan says the medical records show
your condition has been successfully controlled with medication rather than light therapy. The Qualified Independent Contractor (QIC) overturned the Plans denial. The Plan requested a reopen and stated that the QIC did not apply the correct criteria.

The Plan is correct in this case. Based on the medical records provided, you do not meet the NCD criteria as the
medical records show your condition has previously responded to treatment without UV Therapy. Therefore,
we decided the Plan does not have to pre-approve an ultraviolet light therapy (UV Therapy) box for home use.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150), unspecified preventative procedure, by report (D1999), intraoral - complete series of radiographic images (D0210,) and 2D oral/facial photographic images obtained intraorally or extraorally (D0350) provided December 29, 2020.

You asked the Plan to pay for the comprehensive oral exam, unspecified preventative procedure, intraoral x-rays and 2D oral photographs. You say that you required a second opinion due to poor services received at a previous visit. The Plan denied your request. The Plan says the 2D photographs and unspecified preventative procedure are not covered under your benefits. You have exceeded frequency limits for the comprehensive oral exam and intraoral x-rays.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

We reviewed the file and Medicare rules. The Plan provided documentation showing that a comprehensive oral exam and intraoral x-rays were previously covered on December 9, 2020. Thus, the Plan's frequency limit has been exceeded for those services and they are not covered. You stated you went to the dentist for a regular cleaning second opinion and were dissatisfied with the services provided. The Plan requires prior authorization in order to seek a second opinion which was not obtained in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the 2D photographs and unspecified preventative procedure are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150), unspecified preventative procedure, by report (D1999), intraoral - complete series of radiographic images (D0210,) and 2D oral/facial photographic images obtained intraorally or extraorally (D0350) provided December 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an echocardiography provided on February 18, 2021.

You asked the Plan to pay for the echocardiography. The Plan denied your request. The Plan says prior authorization was not obtained as required under the Plan benefits. Services rendered by non-participating providers require prior authorization as outlined in the enrollee's Evidence of Coverage.

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 echocardiography. 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 an echocardiography provided on February 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0483) provided on December 11, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 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 G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed."

We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not support that 22 or more drug classes were tested on the date of service in question. 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 pay for the drug testing services (G0483) provided on December 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus shot provided on April 5, 2021.

You asked the Plan to pay for the tetanus shot. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says tetanus shots are not covered under your Medicare Part B benefit.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the tetanus shot. The Plan follows the same rules. 

Records do not show that you have been injured or directly exposed to any illness related to the tetanus shot. Therefore, we decided that the Plan does not have to pay for the tetanus shot provided on April 5, 2021.

Benefits for the tetanus shot 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 dental services provided by an out-of-network (OON) 
provider on January 4, 2021 and January 11, 2021. 
 
You asked the Plan to pay for the dental services provided by an OON provider. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says dental services are 
only covered when they are provided by in-network dental providers. 
 
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, dental services provided by an out-of-
network provider are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for the dental services provided by an out-of-network (OON) provider on January 4, 2021 and 
January 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray provided from March 24, 2021, to March 25, 2021.
You asked the Plan to waive the copayment for the x-ray. You say that you are appealing this claim. You say you had to go to the emergency room because your heart rate was very high. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $110 copayment for basic radiological services provided at an in-network outpatient hospital. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the standard $110 copayment for the x-ray.
You have been asked to pay a $77.23 copayment for the x-ray. The x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the x-ray provided from March 24, 2021, to March 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services you received from an out-of-network provider on January 28, 2021.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says out-of-network services are not covered.
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 services at issue in this appeal. 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 the dental services you received from an out-of-network provider on January 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided March 26, 2021.
You asked the Plan to waive the copayment for the x-ray. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied.
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 $110 copayment for outpatient radiology. You have been asked to pay the Medicare allowable amount of $108.43 for the x-ray. The x-ray falls within the outpatient radiology benefit category. The allowable amount is less than the $110 copayment listed in the Evidence of Coverage. 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 x-ray provided March 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D1999, D2950) provided to you on 
March 4, 2021. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says these services 
are 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 services are not among 
those covered under this benefit. The Plan covers only those dental services for which the codes are listed in 
the Evidence of Coverage. Dental codes D1999 and D2950 are not listed, and therefore are not covered. 
Therefore, we decided that the Plan does not have to pay for the dental services (D1999, D2950) provided to 
you on March 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0480, 80307, 82542, 84228) provided on March 23, 2021.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not pre-authorized or emergent. There are network providers available.

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 services at issue in this appeal. 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 lab services (G0480, 80307, 82542, 84228) provided on March 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D0120, D0220, D1110) received February 1, 2021 from the out-of-network provider.

You asked the Plan to pay for the dental services. You say that you did not know that this provider was out-of-network. The Plan denied your request. The Plan says the requested services are not covered when received from 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 items or services are not among those covered under this benefit when they are received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the dental services (D0120, D0220, D1110) received February 1, 2021 from the out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no indication their preferred agent(s) would likely be less effective, and/or 
cause adverse effects for you.

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 
Euflexxa is not medically reasonable and necessary. You have not tried and failed Orthovisc and Monovisc. 
There is no documentation provided indicating that Orthovisc and Monovisc would likely be less effective 
and/or likely have adverse effects for you. Our physician reviewer found that your condition does not meet step 
therapy criteria for Euflexxa. 
 
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 Euflexxa.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dalfampridin.

You asked the Plan to pre-approve Dalfampridin. You say that the medication is necessary. The Plan denied
your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Dalfampridin.

Benefits for Dalfampridin 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 dental fillings (D2331) provided on March 11, 2021. 
 
You asked the Plan to pay for the dental fillings. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the Plan's supplemental dental benefit limits fillings 
to two procedure codes per calendar year. The Plan says that they paid for the two fillings you received on 
February 3, 2021. The Plan says that the fillings you received on March 11, 2021 exceeds your benefit limit. 
 
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, dental fillings are limited to two 
procedure codes per calendar year. The file shows that the Plan paid for the two dental fillings you received on 
February 3, 2021. Therefore, we decided that the Plan does not have to pay for the dental fillings (D2331) 
provided on March 11, 2021.