Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the periodontal scaling and root planing for all 4 quadrants. We decided that the Plan does not have to pre-approve the crown for tooth # 31.
You asked the Plan to pre-approve the periodontal scaling and root planing for all 4 quadrants. You say that you have been advised by 2 dentists that you need a deep root and gum cleaning for all 4 quadrants. You also say that 1 dentist also advised you need a crown for tooth # 31. The Plan says that the requested dental services are not medically necessary.
We decided that the Plan has to pre-approve the periodontal scaling and root planing for all 4 quadrants.
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 the dental services when the services are medically necessary and reasonable.
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 dental services. Our reviewer says that the periodontal scaling and root planing for all 4 quadrants is medically necessary. Our physician reviewer found the documentation of more than four teeth per quadrant, pathological periodontal pockets in all for quadrants and the presence of subgingival calculus, the criteria for periodontal scaling and root planing have been met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to pre-approve the periodontal scaling and root planing for all 4 quadrants.
We also decided that the Plan does not have to pre-approve a crown for tooth # 31.
The reviewer also found that the crown for tooth # 31 is not medically necessary. The reviewer found that due to the lack of significant coronal breakdown of tooth #31 and due to caries or fracture, the criteria for a crown restoration on tooth #31 has not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve the crown for tooth # 31.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).
You asked the Plan to pre-approve the mandibular partial denture. You say that the denture the enrollee currently has was made to fit over a protruding bone. You also say the enrollee had the bone removed and now their current partial does not fit at all. The Plan denied your request. The Plan says this service is allowed one time every 60 months. The Plan also says the records show that the enrollee had this service less than 60 months ago.
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, mandibular dentures (one of D5120, D5140, D5212, D5214) are limited to once per 60 months. The record shows that the enrollee received a mandibular partial denture (D5212) on February 7, 2019 and the enrollee's mandibular denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveGel-One 30mg/3ml syringe for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plans preferred viscosupplements are Orthovisc and Monovisc and do not require prior authorization.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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found there is no evidence of a trial andfailure of Orthovisc and Monovisc. The documentation does not support that Orthovisc and Monovisc would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.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 drug have not been met.Therefore, we decided that the Plandoes not haveto pre-approveGel-One 30mg/3ml syringe for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forservices provided on January 17, 2018.You asked the Plan to pay forthe ambulance service. You say that the transport was not included in the hospice benefit.The Plan denied your request. The Plan says Original Medicare is responsible for this claim.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these serviceswhen services are provided on the date of election.was under the Medicare hospice benefit on the dateof service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forservices provided on January 17, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing provided to the enrollee on June 25, 2019.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this was not medically necessary.
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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the requested testing is not medically necessary under Medicare because it is not FDA approved for use in any cancer other than non-small cell lung cancer, and has no clinical utility in the scope of the enrollee's type of cancer. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the testing provided to the enrollee on June 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran inpatient hospital stay provided from July 3, 2019 to July 6, 2019.You asked the Plan to waive the copayment forinpatient stay. You say that you are requesting that the Planextend the benefits of its medical financial assistance program to cover this copayment.The Plan denied your request. The Plan says the copayment amount the enrollee is being charged is correct.The rules say a plan must disclose to its enrollees inclear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The contract with the Plan clearly says that enrollees must pay $285 copayment per day for days 1 to 7 for inpatient stay. This inpatient stay lasted 3 days, resulting in a copayment obligation of $855. has been asked to pay $285 copayment per day for days 1 to 7 for inpatient stay. Inpatient stay falls within the Inpatient Hospital Care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran inpatient hospital stay provided from July 3, 2019 to July 6, 2019.Please note that we do not have jurisdiction to address any benefits the enrollee may receive. Please contact the Plan directly for more information about this program.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for incision and drainage services provided to the enrollee on September 10, 2019.
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 HCPCS code 20005 is no longer active for this date of service.
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 definition of HCPCS code 20005 is "Incision and drainage of soft tissue abscess, subfascial (ie, involves the soft tissue below the deep fascia)." We find that HCPCS code 20005 is not supported. Specifically, as of 1/1/19, this code is considered obsolete by Medicare. 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 incision and drainage services provided to the enrollee on September 10, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedure, occupational therapy evaluation,
performance assessment, and therapeutic activities provided from August 27, 2019 to August 30, 2019.
You asked the Plan to pay for the occupational therapy services. You say that the enrollee was discharged from
hospice on August 16, 2019. The Plan denied your request. The Plan says upon discharge or revocation, fee-for-
service Medicare continues to cover the enrollee through the end of the month when the enrollee revokes or
is discharged from hospice alive. The Plan also says that at the start of the month following revocation or
discharge, all billing and coverage revert back to the managed care plan.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on August 16, 2019. The services in question were provided before
the end of that month. Therefore, we decided that the Plan does not have to pay for the therapeutic procedure,
occupational therapy evaluation, performance assessment, and therapeutic activities provided from August 27,
2019 to August 30, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for Emergency Department services provided on June 2, 2019.You asked the Plan to pay for the Emergency Department services. You say that you have received a duplicate denial in error and a payment or original denial has not been received. The Plan denied your request. The Plan says the member was enrolled in hospice on this date of service and Original Medicare covers hospice care.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicarehospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay for Emergency Department services provided on June 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for arthrocentesis, aspiration and/or injection, major joint or bursa (20611), and the coinsurance for a gelsyn-3 injection (J7328) provided on April 24, 2019.
You asked the Plan to waive the copayment for arthrocentesis, aspiration and/or injection, major joint or bursa (20611) arthrocentesis, aspiration and/or injection, major joint or bursa and the coinsurance for an injection. You say that your client states that these claim denials are unwarranted and unfair. You say that other claims for the same procedures have been paid in the past and you expect this claim to be paid as well. The Plan denied your request. The Plan says an office visit with a specialist has a $50 copayment and Medicare Part B prescription drugs have a 20% coinsurance.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $50 copayment for physician services and a 20% coinsurance for Medicare Part B prescription drugs.The enrollee has been asked to pay a $50 copayment for arthrocentesis, aspiration and/or injection, major joint or bursa and a 20% coinsurance for an injection. These services fall within the physician services and Medicare Part B prescription drugs benefit category. The allowable amount $623.22 x 20% = $124.64 + $50 = $174.64.
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for arthrocentesis, aspiration and/or injection, major joint or bursa (20611), and the coinsurance for a gelsyn-3 injection (J7328) provided on April 24, 2019.
Your complaint about the claims not being covered by the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on February 27, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 95999 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 95999 is unlisted neurological or neuromuscular diagnostic procedure. We find that CPT code 95999 is not supported in the medical record. Specifically, the records show that train of four testing was performed and there is a more appropriate code for these services. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the services rendered to the enrollee on February 27, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve ONPATTRO for the enrollee.You asked the Plan to pre-approve ONPATTRO. You say that this is medically necessary.The Plan denied your request. The Plan says that that the requested medication is not being prescribed by or in consultation with a neurologist, geneticist, or a physician who specializes in the treatment of amyloidosis.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 ONPATTRO. Our reviewer says that ONPATTRO is medically reasonable and necessary for the enrollee in this case. The health plan has not argued that the medication is not indicated or not medically necessary. The health plan argued that the provider prescribing the medication is not of the correct specialty. Interpretation of the record is that the enrollee sees multiple specialists, and that the enrollee's primary care provider is ordering the medication as a matter of practicality. The primary care provider is implementing the paperwork for the drug, the infusion center and the financial assistance. The primary care provider appears to be coordinating the care, as is a primary care provider 's function, which was initiated following a visit to the clinic. Our physician reviewer found that the enrollee's condition meets criteria for coverage of ONPATTRO.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ONPATTRO have been met.Therefore, we decided that the Plan has to pre-approveONPATTRO for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on June 26,
2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the
documentation submitted did not include a valid physician order/lab requisition or medical records.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was to be performed. Based on this information, we decided that
Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan
does not have to pay for the drug testing services provided to the enrollee on June 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered to the enrollee from July 20, 2019 to July 27, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.
We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare
and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does
not have to pay for the home infusion therapy rendered to the enrollee from July 20, 2019 to July 27, 2019.
Benefits for these services 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services provided to the enrollee from July 18, 2019, to July 25, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a valid code.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. We looked at the file and Medicare rules. Code S9328 is assigned a status indicator of "I" under the Physician Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. 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 home infusion therapy services provided to the enrollee from July 18, 2019, to July 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe retail products and first intraoral periapical x-ray provided on May 15, 2019.You asked the Plan to pay forthe retail products and first intraoral periapical x-ray. You say that you realize this dental claim is not covered because you had to go to an out-of-network provider. You also say that you could not wait for days to be seen by an in-network provider because you were in excruciating pain.The Plan denied your request. The Plan says these services are not covered benefits under Medicare Plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe retail products and first intraoral periapical x-ray provided on May 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha for the enrollee.
You asked the Plan to pre-approve Repatha. You say that the enrollee has a history of coronary artery disease and hyperlipidemia. The Plan denied your request. The Plan says Repatha to be taken at home is not covered under the Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha for the enrollee.
Benefits for Repatha 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea physical therapy evaluation (97161, 97162, 97163), therapeutic exercises (97110), electric stimulation therapy (97014), manual therapy (97140), electrical stimulation (97032), electric current therapy (97033), and ultrasound therapy (97035) with out of network (OON) provider. You asked the Plan to pre-approvethese services. You say that you are requesting a reconsideration of the Plan's denial as the requested provider is only one mile from your home. You also say the Plan referred provider is significantly farther and you have concerns for your well-beingwith the Covid-19 issues.The Plan denied your request. The Plan says you have requested services with an out of network provider. The services are available within the Plan's networkof providers within a reasonable distance.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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services.Therefore, we decided that the Plan does not have to pre-approvea physical therapy evaluation (97161, 97162, 97163), therapeutic exercises (97110), electric stimulation therapy (97014),manual therapy (97140), electricalstimulation (97032), electric current therapy (97033), and ultrasound therapy (97035)with the out of network (OON) provider.