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

We decided that the Plan does not have to pre-approve three gingival flap procedures of four or more contiguous teeth or tooth bounded spaces per quadrant (D4240 x3) and one gingival flap procedure of one to three contiguous teeth or tooth bounded spaces per quadrant (D4241).
You asked the Plan to pre-approve the gingival flap procedures. You say that you need to have the gum surgery completed. The Plan denied your request. The Plan says these services are not covered under your benefit package.
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 pre-approve three gingival flap procedures of four or more contiguous teeth or tooth bounded spaces per quadrant (D4240 x3) and one gingival flap procedure of one to three contiguous teeth or tooth bounded spaces per quadrant (D4241).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee on December 4, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says the appropriate home health data "Type of Bill" was not billed correctly. The plan would accept a submission of a corrected claim to consider services for payment.
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, the "Type of Bill" code reported on the claim submitted is not correct and is preventing payment. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee on December 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional radiofrequency ablation services.
You asked the Plan to pre-approve additional radiofrequency ablation services. You say that these services are medically necessary to treat the enrollee's condition. The Plan denied your request. The Plan says the services have been exhausted based on Medicare rules.
The Plan must follow Medicare rules. Medicare rules say that two radiofrequency ablation sessions for each covered spinal region will be reimbursed per year. We looked at the file and Medicare rules. In this case, the case record indicates that the enrollee has already had two radiofrequency ablation sessions for the requested spinal region. Based on this information, we decided that Medicare rules for coverage of additional radiofrequency ablation services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional radiofrequency ablation services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted following cardiac arrest from acute respiratory failure. The enrollee is severely cognitively impaired and requires nasal cannula oxygen without which she rapidly desaturates. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the wheelchair features (E2377, E2313, E2311, E2300).

You asked the Plan to pre-approve the wheelchair features. You say that the features should be covered. The Plan denied your request. The Plan says they will overturn the request for a group 3 power wheelchair, but the seat elevation feature (E2300) or electronic switches and the associated components (E2377, E2313, E2311) are not covered.

The Plan follows Medicare rules. Medicare rules say that power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. Since the enrollee is able to the control of the power options with their own switches, there is no need to control the power option through the joystick. The approved power options come with their own switches. And a power seat elevation feature is noncovered because it is primarily nonmedical in nature. Therefore, we decided that the Plan does not have to pre-approve the wheelchair features (E2377, E2313, E2311, E2300).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc (J7325).
You asked the Plan to pre-approve Synvisc. You say that the enrollee has tried and failed conservative and analgesic treatments. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, 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 Synvisc. Our reviewer says that the requested drug, Synvisc, is not medically necessary. Our physician reviewer found the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. The reviewer found that step therapy, as outlined by the Plan, requires that these be trialed first. The reviewer found that the documentation does not outline contraindications or reasons these medications were not considered. Therefore, the reviewer found that without the support of the documentation, Synvisc cannot be approved, as step criteria have not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc have not been met. Specifically, the record does not show that the enrollee has tried and failed the preferred drugs. Therefore, we decided that the Plan does not have to pre-approve Synvisc (J7325).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CPAP machine and supplies (CPT code(s): A7039, A7034, A7033, A7035) to be provided by an out-of-network provider.

You asked the Plan to pre-approve the supplies. You say that you are requesting to be sent to some out-of-network provider because customer service continuously sends you back to the provider. You state you do not want to use the provider due to a variety of complaints. The Plan denied your request. The Plan says the provider you requested is not part of your primary care physician's network. The Plan states your appeal tells them that you are not satisfied with the group's provider because they did not approve an out-of- network provider for your CPAP and supplies. The Plan states there is a grievance procedure for issues with medical care or office procedures.

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 CPAP machine and supplies (CPT code(s): A7039, A7034, A7033, A7035) to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office services (CPT code(s): 99244, 99204, 99214) to be provided by an out-of-network provider.
You asked the Plan to pre-approve the office services. You say that you are losing your eyesight every day and this provider could help save the remaining vision. The Plan denied your request. The Plan says this is not a network provider and the service is available to be provided in-network.
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 the office services (CPT code(s): 99244, 99204, 99214) to be provided by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PET scan of the brain (78608).
You asked the Plan to pre-approve a PET scan of the brain. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for a PET scan of the brain have not been met because the requested services are 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 a PET scan of the brain. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is noted to have a cognitive impairment. However, the enrollee has not been found to meet diagnostic criteria for both Alzheimer's disease and frontotemporal dementia. Rather the enrollee is not readily suspected of having Alzheimer's disease (based on neuropsychological testing). There are also other potential causes of dementia noted to be present in this case. The requested service ultimately would not meet the criteria for coverage at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PET scan of the brain have not been met. Therefore, we decided that the Plan does not have to pre-approve a PET scan of the brain (78608).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the custom fabricated abutment (D6057) and abutment supported crown (D6059).
You asked the Plan to pre-approve the custom fabricated abutment (D6057) and abutment supported crown (D6059). You say that the crown repair is medically necessary because it causes bacteria buildup, gum discomfort, tongue sores. You say that you're requiring $1,155 if not approved for the full amount and are asking for assistance. The Plan denied your request. The Plan says the services are not covered benefits.
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 pre-approve the custom fabricated abutment (D6057) and abutment supported crown (D6059).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care continuation.

You asked the Plan to pre-approve the SNF care. You say that the enrollee requires a continuation of SNF care. The Plan denied your request. The Plan says the enrollee does not 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 the SNF care. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.

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 SNF care have not been met. Specifically, the file does not show that the enrollee requires daily skilled services. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care continuation.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network
(OON) provider.
You asked the Plan to pre-approve specialist services. You say that you would like approval for these services
to be provided out-of-network. The Plan denied your request. The Plan says there are in-network providers
available for these services.
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
specialist services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on November 10, 2020.
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you were told that you would only owe a $40 specialist copayment and were not informed you would owe anything for the Medicare Part B drug. 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 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug on November 10, 2020. The total allowed amount is $4,605 and 20% of
that is $921. You have been asked to pay the total coinsurance amount of $921 for a Medicare Part B drug. A Medicare Part B drug falls within the Medicare Part B prescription drugs 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 for a Medicare Part B drug provided on November 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the resin-based composites.

You asked the Plan to pre-approve the resin-based composites. You say that your teeth are short, and they are hitting the gum line. You say that the provider advised you to have this work and it is not for cosmetic reasons. The Plan denied your request. The Plan says the service is not a 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 pre-approve the resin-based composites.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prostate gene expression profile.

You asked the Plan to pre-approve the requested testing. The Plan denied your request. The Plan says no major risk factors for prostate cancer has been documented.

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 requested testing Our physician reviewer found that it is documented that the enrollee's prostate antigen (PSA) has declined to normal for age 81. He reported intermittent gross hematuria over several weeks. It was noted that he had prostate asymmetry but no true nodule. The documentation does not support that the requested oncology (prostate) gene expression profile is medically reasonable and necessary for the enrollee in this case and would impact his management and outcome.

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 requested testing have not been met. Therefore, we decided that the Plan does not have to pre-approve a prostate gene expression profile.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for chiropractic services.

You asked the Plan to waive the copay for chiropractic services. You say that the Plan wrongfully denied coverage. You also say that you cannot afford to pay these bills. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for Chiropractic Services. Although your provider is out of network, the Plan has covered the services at the in-network benefit level. 

You have been asked to pay a $20 copayment for each chiropractic service. This service falls within the Chiropractic 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 copay for chiropractic services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower denture (D5214).

You asked the Plan to pre-approve the partial dentures. You say that you need these services. The Plan denied your request. The Plan says dentures are covered once every 5 plan years. The Plan also says that the frequency limit has been reached.

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 and partial dentures are listed as covered, the frequency limits have been reached. The record shows that the Plan paid for partial dentures that you received on February 22, 2017. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower denture (D5214).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for transportation services provided on October 22, 2020.

You asked the Plan to waive the copayment for transportation services provided on October 22, 2020. You say that you drove your father to the urgent care to have his labs checked, but they did not draw any blood. You say that since they called an ambulance instead, you do not feel the $75 copayment should be your responsibility. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay $75 copayment for Ambulance Services. 

The enrollee has been asked to pay $75 copayment for transportation services. Transportation services fall within the Ambulance Services 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 for transportation services provided on October 22, 2020.