Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora breast cancer screening provided on August 22, 2019.You asked the Plan to waive the coinsurance fora breast cancer screening. You say that you disagree with the out-of-network charges because you have used this provider for over 10 years.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 mustpay 50% coinsurance for out-of-network breast cancer screenings. You received a breast cancer screening on August 22, 2019 with an out-of-network provider. The allowed amount is $122.67 and 50% of that is $61.33. You have been asked to pay the total coinsurance amount of $61.33 for a breast cancer screening. A breast cancer screening falls within the breast cancer screenings 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 coinsurance fora breast cancer screening provided on August 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 10, 2019 to the enrollee by an out of network (OON) provider.
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 were rendered by an out-of-network provider without prior authorization.
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 has network providers available who can provide 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 the medical services provided on September 10, 2019 to the enrollee by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound rendered to the enrollee on December 3, 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 were not billed correctly.
The Plan must follow Medicare rules. The rules say that Medicare may not pay for the TC of radiology services furnished to Skilled Nursing Facility (SNF) inpatients during a Part A covered stay. We looked at the file and Medicare rules. The provider submitted a claim for the TC of radiology services while the enrollee was inpatient at a SNF. Therefore, we decided that the Plan does not have to pay for the ultrasound rendered to the enrollee on December 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromonitoring services provided to the enrollee on May 21, 2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the documentation did not indicate the billed services were provided.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The file shows that neuromonitoring services as identified by procedure codes 95868, 95870, 95937, and G0453, were billed for services provided to 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 pay for the services provided. Our physician reviewer found that the date of service in question is May 21, 2019. The records provided are from May 7, 2019. Therefore, there is no evidence to support the services billed on the date of service in question. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the neuromonitoring services provided to the enrollee on May 21, 2019.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay forthe core build-up including any pins when required tooth #9. We decided that the Plan does not haveto pay forthe retainer crown porcelain fused to high noble metal tooth #9. You asked the Plan to pay forthe core build-up including any pins when required tooth #9. You say that you have a balance at your dentist because of work you had done that was pre-approved. If it was not approved you would not have gotten the work done.The Plan says that this request exceeds the benefit frequency limitation of once procedure every 5 years.We decided that the Planhas to pay forthe core build-up including any pins when required tooth #9. The Plan follows Medicare rules. 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 on page 4-54 says coverage frequency/limitations for core build-up including any pins when required, is unlimited per plan year.Therefore, we decided that the Plan has to pay forthe core build-up including any pins when required tooth #9. We also decided that the Plandoes not have to pay forthe retainer crown porcelain fused to high noble metal tooth #9.
The Plan follows Medicare rules. 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. Per the health plan contract on page 4-53 says that coverage frequency/limitations for crown-porcelain fused to high noble metal, is covered once every 5 years. The records show that this service was provided January 2, 2018. Therefore, this procedure is not eligible for coverage. Therefore, we decided that the Plan does not have to pay forthe retainer crown porcelain fused to high noble metal tooth #9
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a multi-focal intraocular lens.
You asked the Plan to pre-approve the lens. You say that this is medically necessary. The Plan denied your request. The Plan says the requested lenses are an add-on feature for the basic lenses.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pre-approve are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pre-approve a multi-focal intraocular lens.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the temporary equipment rental provided on September 19, 2019. You asked the Plan to pay for the temporary equipment rental. You say that the Plan should pay this claim. The Plan denied your request. The Plan says without the requested information they cannot determine whether the services were necessary. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There are no records supporting necessity of this service. Based on this information, we decided that Medicare rules for coverage of the temporary equipment rental have not been met. Therefore, we decided that the Plan does not have to pay for the temporary equipment rental provided on September 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.You asked the Plan to pre-approve the drug. You say that the enrollee has now tried Boniva and has failed.The Plan denied your request. The Plan says step therapy guidelines were not followed.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 the provided medical records do not indicate that the enrollee has tried and failed Zoledronic acid. There is no history of osteoporotic fracture. The plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pregabalin capsules.You asked the Plan to pre-approvePregabalin capsules. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says Pregabalin capsules are not covered under the enrollee's Medicare 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-approvePregabalin capsules.Benefits for Pregabalin capsulesmay be available under Medicare Part D.Contactthe 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 pre-approve a crown (D2750), a prefabricated post and core in addition to a crown (D2954), and a root canal (D3330) for tooth # 18.
You asked the Plan to pre-approve the dental services. You say that the enrollee's tooth # 18 has a large restoration, palpation positive, percussion positive and nerve involvement. You also say that the enrollee is in a lot of pain. The Plan denied your request. The Plan says the x-rays provided do not show that the requested dental services are medically necessary for tooth # 18.
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 requested dental services are not medically necessary. Our physician reviewer found the documentation that was provided is not adequate to make a determination of medical necessity for the services indicated. The reviewer found that there was no radiograph of tooth # 18 to determine if there was significant breakdown of the coronal structure to warrant a post and core, and crown restoration or if there was an indication of periapical pathology to determine if root canal treatment was indicated. Therefore, the requested dental services are not medically necessary. 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 a crown (D2750), a prefabricated post and core in addition to a crown (D2954), and a root canal (D3330) for tooth # 18.
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 you called 911 due to suddenly suffering acute pain in your left leg. When the paramedics arrived, they evaluated you and offered you transport to the hospital. You say that you declined because you didn't believe it was necessary after the pain stopped.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 November 6, 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 pre-approveMyocardial Perfusion Imaging (SPECT) (78452).You asked the Plan to pre-approvethe Myocardial Perfusion Imaging. You say that the imaging is medically necessary.The Plan denied your request. The Plan says coverage criteria is 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 pre-approve the Myocardial Perfusion Imaging. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the patient has increased risk for coronary stenosis including coronary calcification but no symptoms suggestive of coronary stenosis, no cardiac physical exam abnormalities and no acute ischemic electrocardiography changes.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 Myocardial Perfusion Imaging have not been met.Therefore, we decided that the Plan does not have to pre-approveMyocardial Perfusion Imaging (SPECT) (78452).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to the physician.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says this service is able to be completed with an in-network provider.
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 a referral to the physician.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 3, 2019 to the enrollee by an out of network (OON) provider.
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 were rendered by an out-of-network provider without prior authorization.
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 has network providers available who can provide 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 the medical services provided on September 3, 2019 to the enrollee by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a lower partial denture (D5214).You asked the Plan to pre-approve the dental service. You say that you have had dentures previously. You say that your teeth are healthy and can support dentures. You say that you told the dentist you would not pay for the dentures but your plan would. You say that this is when the dentist changed their mind and said there was a problem with your teeth. You also say that you would like a second opinion.The Plan denied your request. The Plan says that the partial dentures do not meet the criteria for coverage.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 service 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 service. Our reviewer says that the service is medically necessary. Our physician reviewer found the documentation provided indicates an edentulous maxilla and the presence of 3 remaining mandibular teeth, 22, 27 and 28. The reviewer found that the remaining mandibular teeth have good bone support. The reviewer found that any caries could be restored effectively to adequate function. The reviewer also found that these teeth would adequately support a mandibular removable partial denture. Therefore, the partial denture is medically necessary.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 service have been met.Therefore, we decided that the Plan has to pre-approve a lower partial denture (D5214).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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by provider. You asked the Plan to pre-approve physical therapy. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.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-approve physical therapy to be provided by provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care after April 10, 2020.You asked the Plan to pre-approve the continuation of skilled nursing facility (SNF) care. You say that the continuation of SNF care is medically necessary.The Plan denied your request. The Plan says the continuation of SNF care does not meet criteria.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the continuation of skilled nursing facility (SNF) care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee suffered a fractured hip (closed) of the right hip. As of 4/2/2020, the member is able to make basic needs known, and is non-toxic and afebrile. The member has mixed bowel/bladder incontinence. Functional mobility and transfers require supervision as per therapy notes. She is comfortable at rest and is full weight bearing. Medications include Alendronate. Diet consistency is regular. The enrollee is now mostly supervised for all care. The enrollee has no complex wound care needs, or IV medication requirements. There are no nursing or therapy needs that are skilled, and warranting a SNF as opposed to a lesser level of care (including home health care services). The enrollee's vital signs are stable; the enrollee is tolerating an oral diet; has no new and/or significant bowel or bladder deficits; and pain is controlled. Continued SNF is not necessary.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 continuation of skilled nursing facility (SNF) care have not been met.Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care after April 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjunctive dental procedure provided on May 24, 2017.You asked the Plan to pay for the adjunctive dental procedure. You say that you were overcharged for this dental service. You also say that the dental office claims that you were not in-network at the time of this appointment.The Plan denied your request. The Plan says this service is not covered by your plan or Medicare.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 adjunctive dental procedure provided on May 24, 2017.