Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for out of network physician services provided on February 23, 2021.
You asked the Plan to pay for out of network services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network physician services provided on February 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve panniculectomy.
You asked the Plan to pre-approve panniculectomy. You say that the enrollee has been seen for years due to rashes. The Plan denied your request. The Plan says the enrollee has not used oral or topical medications to treat the condition.
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 panniculectomy. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that she has a pannus that develops intertrigo that is responsive to topical treatment. The elements of the coverage criteria are not satisfied. The requested service 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 panniculectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve panniculectomy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the crown (D2752)
provided on April 1, 2021.

You asked the Plan to pay for the dental services. You say that your premium was reduced for 2021. You say
that you called customer service to make sure you still had dental coverage. You say that you were advised you
did have dental coverage. You also say that the crown should be covered at 30% because you were not
informed of the change in your coverage. The Plan denied your request. The Plan says the annual notice of
changes (ANOC) for 2021 was mailed to you in September 2020. The Plan says that the ANOC shows changes
to your plan for the upcoming year.

The Plan also says there was no mention by you of a policy prior to this year, and only requested a dentist and 
verified benefits for cleaning and routine exam on your current active plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
limited oral evaluation (D0140) and the crown (D2752) provided on April 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on November 5, 2020 and billed under code 99153.

You asked the Plan to pay for codes 99152 and 99153. The Plan denied your request. The Plan says while code 99152 was paid, code 99153 has a PC/TC indicator of three (3), for a technical component only code as defined in Medicare Claims. The Plan says that Medicare billing guidelines state code 99153 is a technical component only code and cannot be paid as billed. The Medicare rule for payment of this claim are not met.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, code 99153 cannot be paid as billed as technical codes should not be paid separately on an inpatient facility claim. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on November 5, 2020 and billed under code 99153.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power wheelchair features and accessories defined by billed codes K0108, K0108, E2377, E2313, and E2311.
You asked the Plan to pre-approve the power wheelchair features. You say that the wheelchair features should be covered. The Plan denied your request. The Plan says they will overturn the coverage of the power wheelchair itself, but the features E2377 Expandable Controller, E2313 Expandable Controller Harness and E2311 Electro Connect Btw 2 Sys Electro Connect Btw 2 Sys are not required.
The Plan must follow Medicare rules. Medicare rules say that items that are necessary will be covered. The electrical connection between the wheelchair controller and two or more motors (E2311), expandable controller (E2377) and harness (E2313) are not covered. Although there are three approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a need to control these power options through the joystick, which is what these specific codes provide. The approved power options come with their own switches already. There is a request for K0108 F3 Hub Cap Color, and K0108 Color Kit Mossy Oak. These do not serve a medical purpose. They are not covered as they are not reasonable and necessary per Medicare criteria. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the power wheelchair features have not been met. Therefore, we decided that the Plan does not have to pre-approve the power wheelchair features and accessories defined by billed codes K0108, K0108, E2377, E2313, and E2311.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that it would be a danger and unsafe to go home alone with no help. The Plan denied your request. The Plan says that you no longer require daily skilled services.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for continued SNF services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve blepharoplasty.

You asked the Plan to pre-approve these services. You say that you would like this procedure covered. The Plan denied your request. The Plan says that medical need has not been shown.

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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. You have dermatochalasis of both eyes. The provided records explicitly state that the requested procedure is currently cosmetic, rather than functional, in nature. Our physician reviewer found that your condition does not meet Medicare criteria for these services. 

We looked at this physician's review, the file, and Medicare rules. 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 pre-approve blepharoplasty.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the exchanging of drainage catheters, an
injection procedure, catheter removal and an X-ray provided from January 11, 2021, to March 18, 2021.
You asked the Plan to waive the copayments for the exchanging of drainage catheters, an injection procedure,
catheter removal and an X-ray. You say that you feel that you should only owe one copayment and not four.
You also feel that the X-ray should be included in the procedures. 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 $250
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers. Your contract with the Plan also clearly says that you must pay a $10 copayment for X-rays.
You received the exchanging of drainage catheters on January 11, 2021, and January 26, 2021 for a total of 2
services. The exchanging of drainage catheters is considered outpatient surgical procedures. Therefore, you are
responsible to pay a $250 copayment per each surgery. The total amount you owe for this type of surgery is:
$500.
You received an injection procedure on February 3, 2021. An injection procedure is considered an outpatient
surgical procedure. Therefore, you are responsible to pay the $250 copayment.
You received catheter removal on February 11, 2021. Catheter removal is considered an outpatient surgical
procedure. Therefore, you are responsible to pay the $250 copayment.
You received an X-ray on March 18, 2021. Therefore, you are responsible to pay the $10 copayment.
The total amount you owe is: $1,010.
You have been asked to pay the total copayment amount of $1,010 for the exchanging of drainage catheters, an
injection procedure, catheter removal and an X-ray. The exchanging of drainage catheters, an injection
procedure, and catheter removal fall within the outpatient surgery, including services provided at hospital
outpatient facilities and ambulatory surgical centers benefit category. An 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
copayments for the exchanging of drainage catheters, an injection procedure, catheter removal and an X-ray
provided from January 11, 2021, to March 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two preventive procedures (D1999 x2), and sales tax (D9985 x2), and to pay more for the periodic oral evaluation (D0120), panoramic x-ray (D0330), prophylaxis (D1110), resin-based composite (D2392), crown (D2740), and core buildup, including any pins when required (D2950) provided on March 2, 2021, and March 4, 2021 by an OON provider.
You asked the Plan to pay for the preventive procedures, and sales tax, or pay more for the periodic oral evaluation, panoramic x-ray, prophylaxis, resin-based composite, crown, and core buildup. You say that the balance of the $1,000.00 dental coverage is still due to you. The Plan denied your request. The Plan says the preventive procedures and sales tax are not covered benefits.
The Plan also says that the claims for the periodic oral evaluation, panoramic x-ray, prophylaxis, resin-based composite, crown, and core buildup processed correctly.
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, unspecified preventive procedure (D1999) and sales tax (D9985) are not among those covered under this benefit. You are also responsible for a 50% coinsurance for crowns and core buildups, plus the difference between the billed amount and allowed amount for services received OON. Therefore, we decided that the Plan does not have to pay for the two preventive procedures (D1999 x2), and sales tax (D9985 x2), and to pay more for the periodic oral evaluation (D0120), panoramic x-ray (D0330), prophylaxis (D1110), resin-based composite (D2392), crown (D2740), and core buildup, including any pins when required (D2950) provided on March 2, 2021, and March 4, 2021 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81401, 81403, 81404, 81405, 81406, 81407, 81408 and 81479 provided on January 12, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 81401, 81403, 81404, 81405, 81406, 81407, 81408 and 81479 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. This means codes 81401, 81403, 81404, 81405 and 81406 are not payable. Codes 81407, 81408 and 81479 are not payable as billed due to the testing was not ordered/approved by the ordering provider.
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81401, 81403, 81404, 81405, 81406, 81407, 81408 and 81479 provided on January 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and five surgical extractions (D7210 x5) to be rendered by an oral surgeon.

You asked the Plan to pre-approve the comprehensive oral evaluation and extractions. You say that you cannot afford to pay for the extractions yourself. The Plan denied your request. The Plan says dental services performed by an oral surgeon 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 items or services are not covered when they are received by an oral surgeon. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and five surgical extractions (D7210 x5) to be rendered by an oral surgeon.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital from February 25 through March 1, 2021.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were not aware that inpatient hospital stays would be this expensive, and you cannot afford this copayment. 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 $350 copayment per day for Inpatient Hospital Care. You have been asked to pay a $1050 copayment ($350 per day for days 1 - 5, and $0 after day 5) for the inpatient hospital stay. The inpatient hospital stay falls within the Inpatient Hospital 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 the copayment for the inpatient hospital from February 25 through March 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from December
8, 2020, through February 11, 2021.
You asked the Plan to waive the copayment for physical therapy. You say that you were told that all the claims
that processed with a copayment would be reprocessed. You say that you may not have continued physical
therapy if you knew it wasn't covered. The Plan denied your request. The Plan says the copayments applied
correctly.
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 2020 contract with the Plan clearly says that you must pay a
$25 copayment for each Medicare-covered physical, occupational, or speech language therapy visit. Your 2021
contract with the Plan clearly says that you must pay a $10 copayment for each Medicare-covered physical,
occupational, or speech language therapy visit.
You have been asked to pay a total of $120 for physical therapy.
Date of Service Service Copayment Number of Visits Member Liability
December 8, 2020-
December 10, 2020
Physical Therapy $25/visit 3 $60-Met Maximum
Out of Pocket
January 22, 2021-
February 11, 2021
Physical Therapy $10/visit 6 $60
TOTAL: $120
Physical therapy falls within the "Outpatient rehabilitation services" benefit category. This means that you have
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for physical therapy provided from December 8, 2020, through February 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane, left knee inj.

You asked the Plan to pre-approve Durolane, Hyaluronan or derivative, durolane, for intra-articular injection, 1 mg (J7318). You say that you would like to treat the enrollee with this drug for knee pain. The Plan denied your request. The Plan says the enrollee has not tried and failed Orthovisc and Monovisc.

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 Durolane, Hyaluronan or derivative, durolane, for intra-articular injection, 1 mg (J7318). 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 drugs. Based on the medical records provided there is no indication that the plan's required drugs 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 Durolane, Hyaluronan or derivative, durolane, for intra-articular injection, 1 mg (J7318) have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane, left knee inj.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa (J7323).
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says the information submitted does not meet the Plan's medical necessity guidelines for coverage.
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 the elements of the coverage criteria are not satisfied. Our physician reviewer found the record indicates that the enrollee has osteoarthritis of the knees. The requested medication is a new start. Our reviewer found that the provided records do not indicate that the enrollee has tried and failed the Plan's preferred step one alternatives. Our physician reviewer also found that the record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one alternatives. 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 (J7323).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for cardiac rehabilitation.
You asked the Plan to pre-approve the referral. You say that this is medically necessary for non-rheumatic aortic (valve) stenosis. The Plan denied your request. The Plan says there are no in-network inadequacies.
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 out-of-network referral for cardiac rehabilitation.