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

We decided that the Plan does not have to pay for the first intraoral periapical x-ray and panoramic x-ray provided on November 26, 2019.You asked the Plan to pay for the first intraoral periapical x-ray and panoramic x-ray. You say that the provider should have known what benefits were covered for you, and should not have done these x-rays without getting approval from your plan first.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, bite wing x-rays are the only x-rays covered under your benefit Plan. First intraoral periapical x-ray and panoramic x-ray are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray and panoramic x-ray provided on November 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for resin-based composite, three surfaces, posterior tooth 3 (D2393) provided December 10, 2019.You asked the Plan to pay for the dental services. You say that the provider informed you that you needed 3 fillings and a crown and it would cost $800. You paid $400 upfront. The provider billed the plan $1,600 which included a fourth filling and now you owe $569.The Plan denied your request. The Plan says the service is covered by the benefit maximum has been exhausted.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 health plan contract says that once the $1,000 annual maximum has been exhausted, any remaining charges are your responsibility.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 resin-based composite, three surfaces, posterior tooth 3 (D2393) provided December 10, 2019.MAXIMUS Federal Services read your letter and knows that you may have a quality of care concern. MAXIMUS Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays provided on July 30, 2019. You asked the Plan to pay for the bitewing x-rays. The Plan denied your request. The Plan says that this is a non-covered benefit. 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 bitewing x-rays provided on July 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (J9271).You asked the Plan to pre-approve Keytruda. You say that this is medically necessary.The Plan denied your request. The Plan says this is not supported for the requested use.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. Our reviewer says that Keytruda is not medically necessary in this case. Our physician reviewer found Keytruda is FDA approved for use in small cell lung cancer that has progressed on or after Platinum-based chemotherapy and at least one other prior line of therapy. In this case it is being requested for first line treatment without any evidence of progression. This is not supported in the compendia, therefore the documentation does not support that the Keytruda is safe and effective 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 Keytruda have not been met.Therefore, we decided that the Plan does not have to pre-approve Keytruda (J9271).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for CPAP supplies (A7031, A7037, A7038 and E0562) provided on July 23, 2019.
You asked the Plan to pay for the CPAP supplies. You say that you would like reconsideration because the billed supplies are medically necessary. The Plan denied your request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the documentation provided does not link the supplier's delivery documents with the delivery service records. Therefore, we decided that the Plan does not have to pay for CPAP supplies (A7031, A7037, A7038 and E0562) provided on July 23, 2019.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve17 home health aide visits.You asked the Plan to pre-approve home health aide visits. You say that you need this care.The Plan denied your request. The Plan says that you already have a caregiver who can provide these services.The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 home health aide visits. Our reviewer says that the requested home health services are medically necessary. Our physician reviewer found the records document that you are non-ambulatory and mobile in a wheelchair, require assist with transfers, and are occasionally incontinent of urine. You are dependent for most activities of daily living. The records do substantiate your functional status and the medical necessity for home health aide services. You do have hands-on personal care needs documented in the records that required a home health aide to maintain his health. There are also identifiable skilled nursing and rehabilitation needs documented.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health aide visits have been met.Therefore, we decided that the Plan has to pre-approve17 home health aide visits.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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two gingival irrigations, problem focused limited oral evaluation, pulp vitality tests, and two adjunctive procedures provided from December 9, 2019 to December 27, 2019.You asked the Plan to pay for the gingival irrigations, problem focused limited oral evaluation, pulp vitality tests, and adjunctive procedures. You say that you went to get a cleaning done and were also advised that it would not be covered.The Plan denied your request. The Plan says these services are not covered by your 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. The record shows that you acknowledged and accepted financial responsibility prior to receiving the dental services.Therefore, we decided that the Plan does not have to pay for the two gingival irrigations, problem focused limited oral evaluation, pulp vitality tests, and two adjunctive procedures provided from December 9, 2019 to December 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).You asked the Plan to pre-approve the Prolia. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the member does not meet step therapy exception criteria.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 record does not indicate that the member has tried and failed a trial of zoledronic acid or that zoledronic acid would likely have adverse effects. Our physician reviewer found the record does not indicate that the member has a history of osteoporosis related 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 (J0897).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from April 17, 2019 to April 26, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the acute inpatient hospital care provided from April 17, 2019 to April 26, 2019 was medically necessary. The Plan denied your request. The Plan says that they were unable to make a determination within the allotted time frame.
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 review indicates that the enrollee was admitted through the emergency department on April 17, 2019 with complaints of increasing dyspnea for the past 3 days that had not responded to increased oxygen level and respiratory treatments. She was evaluated and was noted to have decreased air movement on physical exam. Labs including cardiac biomarkers and d-dimer were normal; EKG was without acute ischemic changes and the chest x-ray was normal. She was treated with IV steroids and nebulizer treatments. She was admitted and evaluated by Endocrinology and Gastroenterology. She underwent an upper endoscopy which demonstrated a large hiatal hernia. Her condition stabilized and improved and she was discharged home when considered medically stable with outpatient follow-up on April 26, 2019. The review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 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 for the acute inpatient hospital care provided from April 17, 2019 to April 26, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive a copayment for Emergency Room services (99285) provided December 24, 2019 by provider.You asked the Plan to waive a copayment forthe Emergency Room services. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct cost sharing 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 Emergency Care. You have been asked to pay a $110 copayment for the Emergency Room services. The Emergency Room services fall within the Emergency Care 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 a copayment for Emergency Room services (99285) provided December 24, 2019 by provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services provided on July 5, 2019 billed with codes 15734 and 15734-76-51.You asked the Plan to pay for the billed surgical services. You say that this is correctly coded and should be paid.The Plan denied your request. The Plan says the records do not support this code. 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 15734 is Muscle, myocutaneous, or fasciocutaneous flap; trunk. We asked our coding 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 billed surgical services. Our reviewer says that the documentation does not support the billing of these codes. Our reviewer found per the NCCI Policy Manual in regards to CPT code 15734, "the physician repairs a defect area using a muscle, muscle and skin, or a fasciocutaneous flap. The physician rotates the prepared flap from the donor area to the site needing repair, suturing the flap in place. The donor area is closed primarily with sutures. If a skin graft or flap is used to repair the donor site, it is considered an additional procedure and is reported separately. Report 15733 for a muscle, myocutaneous, or fasciocutaneous flap obtained from the head and neck with named vascular pedicle such as temporalis or sternocleidomastoid; 15734 if obtained from the trunk; 15736 if obtained from an upper extremity; and 15738 if obtained from a lower extremity. Use 15734 to report the flap donor site. Repair of the donor site that requires a skin graft or local flaps is considered an additional, separate procedure and should be coded separately. Extensive immobilization and/or repair of the donor site is reported separately. When 15734 is performed with another separately identifiable procedure, the highest dollar value code is listed as the primary procedure and subsequent procedures are appended with modifier 51. If significant additional time and effort is documented, append modifier 22 and submit a cover letter and operative report.  This description is not documented in the operative note. Neither code is supported. 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 billed surgical services have not been met.Therefore, we decided that the Plan does not have to pay for the surgical services provided on July 5, 2019 billed with codes 15734 and 15734-76-51
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gilenya 0.5mg capsules.You asked the Plan to pre-approve the Gilenya capsules. You say that the enrollee requires this drug to treat her condition.The Plan denied your request. The Plan says this oral drug is not covered by Medicare Part B.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 Gilenya 0.5mg capsules.Benefits for the Gilenya capsules 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided by a provider that does not participate in Medicare from July 11, 2019 to December 15, 2019. You asked the Plan to pay for home health services. You say that home health care services should be covered. The Plan denied your request. The Plan says home health services must be provided by a provider that participates in Medicare. The Plan must follow Medicare rules. Medicare rules say that home health services are covered only when the home health agency that is providing the services to the beneficiary has in effect a valid agreement to
participate in the Medicare program. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. The provider you received these services from does not
participate in the Medicare program. Therefore, we decided that the Plan does not have to pay for home health services provided by a provider that does not participate in Medicare from July 11, 2019 to December 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo (J9299).You asked the Plan to pre-approve Opdivo. You say that the medication is necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.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 Opdivo. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that the Opdivo is medically reasonable and necessary for the enrollee. The documentation does not support that the Opdivo is safe and effective 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 Opdivo have not been met.Therefore, we decided that the Plan does not have to pre-approve Opdivo (J9299).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the acupuncture services you received on January 29, 2020.You asked the Plan to pay for the acupuncture services. You say that you were advised the services would be covered.The Plan denied your request. The Plan says that Acupuncture is not covered under any condition.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.The file shows that you received the acupuncture services by a contract provider. The file does not show that the Plan provided notice that the acupuncture services would not be covered. The Evidence of Coverage you were provided shows incorrect information regarding acupuncture services. Under Medicare rules, this means the acupuncture services is considered approved by the Plan.Therefore, we decided that the Plan has to pay for the acupuncture services you received on January 29, 2020.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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that on the date of service you were driving when you began to feel ill. You pulled off the highway and called 911. The responders came and checked your vitals. You say that you were told by the responders that you seemed fine and so you declined transportation. You say that it does not say anywhere in your Plan documentation that the ambulance services will not be covered if you are not transported. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on October 18, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an electrocardiogram (93005) provided on August 21, 2018.
You asked the Plan to waive the copayment for the electrocardiogram. 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 $100 copayment for diagnostic testing. You have been asked to pay a $100 copayment for the electrocardiogram. The electrocardiogram falls within the diagnostic testing benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an electrocardiogram (93005) provided on August 21, 2018.