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

We decided that the Plan does not have to waive the copayment for the ultrasound provided on October 1,
2020.
You asked the Plan to waive the copayment for the ultrasound. You say that you should only be charged one
copayment because the procedure was done at the same time on both breasts. You do not believe you should
have to pay for two separate procedures. The Plan denied your request. The Plan says you have been asked to
pay 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 $110
copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a
physician's office or at a freestanding facility (such as a radiology center or medical clinic).
You have been asked to pay a $110 copayment for the ultrasound. The ultrasound falls within the "Outpatient
Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The record shows you were billed
for two separate ultrasounds. 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 ultrasound provided on
October 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays provided on October 30, 2020.
You asked the Plan to pay for the bitewing x-rays. You say that you were not aware that bitewing x-rays were only covered once every 12 consecutive months. The Plan denied your request. The Plan says bitewing x-rays are payable once in any period of 12 consecutive months.
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, bitewing x-rays are limited to one set every 12 months. The record shows that you received bitewing x-rays on December 18, 2019 and your bitewing x-rays benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays provided on October 30, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit for the evaluation and management of an
established patient provided on October 15, 2020 by an OON provider.
You asked the Plan to pay for the home visit for the evaluation and management. The Plan denied your request.
The Plan says these services were rendered by an OON provider. The Plan also says that there is no
authorization on file.
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 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 the home visit for the evaluation and management
of an established patient provided on October 15, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve block.
You asked the Plan to pre-approve genicular nerve block. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not met.
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 genicular nerve block. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/ investigational procedure and it is the subject of on-going clinical trials. Therefore, the request is deemed not medically reasonable or 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 genicular nerve block have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve block.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the periodic oral evaluation (D0120), and the prophylaxis (D1110).
You asked the Plan to pay an additional amount for the oral exam and the prophylaxis. You say that the requested services were necessary. The Plan denied your request. The Plan says if you visit an out-of-network dentist you may be billed for additional costs.
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 payment is in excess of that which is covered under this benefit. The provider in this case is not a network provider. The Plan has agreed to pay 100% of the allowed cost for the prophylaxis and oral exam. You have been asked to pay the difference between the amount charged by the out-of-network provider and the plan's allowable charge. Therefore, we decided that the Plan does not have to pay an additional amount for the periodic oral evaluation (D0120), and the prophylaxis (D1110).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit (Q5106).
You asked the Plan to pre-approve Retacrit. The Plan denied your request. The Plan says this request does not
meet Part B coverage criteria for Retacrit.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Retacrit. Our reviewer says that
Retacrit (Q5106) is not medically reasonable and necessary for the enrollee. Our physician reviewer found
based on the medical records provided and the Medicare-approved major drug compendia there is no
documentation that Retacrit is approved by the Food and Drug Administration for this enrollee with anemia
with iron-deficiency without clear documentation to support myelodysplastic syndrome. Our reviewer found
that the use of Retacrit for iron-deficiency anemia is not supported by one of the major drug compendia or by
clinical research that appears in a Centers for Medicare & Medicaid Services approved medical journal. Our
physician reviewer also found that Retacrit for iron-deficiency anemia is not supported by any of the major
drug compendia.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have
to pre-approve Retacrit (Q5106).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON)
provider.
You asked the Plan to pre-approve office visits with an OON provider. You say that you would like the Plan to
reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent
nor urgent to seek out-of-network care. The Plan says there are in-network specialist's available to the enrollee
that can provide the services being requested.
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
office visits to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 8, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The tests at issue in this appeal, the laboratory services, were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on October 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-share for the eye exam (92014) provided on November 19, 2020.
You asked the Plan to waive the cost-share for the eye exam. You say that this was a preventative screening and should have no cost-sharing responsibility. The Plan denied your request. The Plan says this claim was 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 contract with the Plan clearly says that you must pay 15% coinsurance for Medicare-covered vision exams. You have been asked to pay $43.48 for the eye exam. This exam was billed as an ophthalmological evaluation/exam for diagnosis and treatment of diseases and injuries of the eye rather than as a screening service. Therefore, cost-sharing applies.
The Plan provided documentation that you had not yet met your $600 deductible at the time of service. The Plan's allowed amount for this service is $123.92. You were $29.29 short of your deductible, so this amount was applied to your share of the cost. Once your deductible was met, you were responsible for 15% coinsurance on the remaining cost ($123.92 - $29.29 = $94.63 remaining. $94.63 x 15% coinsurance = $14.19.)
You are responsible for the deductible and your coinsurance for this service ($29.29 + 14.19 = $43.48). 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 cost-share for the eye exam (92014) provided on November 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services described by codes D7230 and D7240.

You asked the Plan to pre-approve dental codes D7230 and D7240. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says dental codes D7230 and D7240 are not covered under the Plan's supplemental dental 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, dental codes D7230 and D7240 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental services described by codes D7230 and D7240.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on December 18, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you believe this service should be covered. The Plan denied your request. The Plan says this procedure is limited to twice per calendar year.
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, oral examinations are limited to two per calendar year. The record shows that you received oral examinations on March 11, 2020, and November 19, 2020 and your oral examinations benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on December 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intracept procedure.
You asked the Plan to pre-approve an intracept procedure. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not met.
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 an intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the intracept procedure is experimental for back pain. More research is needed to show safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the manual wheelchair base and leg rest (K0195RR, K0001RR).
You asked the Plan to pre-approve the manual wheelchair. You say that the enrollee requires a manual wheelchair. The Plan denied your request. The Plan says the manual wheelchair base and leg rest are not proven necessary in the documentation.
The Plan follows Medicare rules. Medicare rules say that the enrollee must have a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home to qualify for coverage of a manual wheelchair. Additionally, there must be documentation showing that the mobility limitation cannot be sufficiently resolved by use of an appropriately fitted cane or walker. 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 manual wheelchair. Our reviewer says that the documentation does not show that the service is medically necessary. Our physician reviewer found there is no documentation that the beneficiary has a mobility limitation that significantly impairs their ability to participate in mobility-related activities of daily living (MRADL's). There is no documentation that any mobility limitation cannot be sufficiently resolved by use of an appropriately fitted cane or walker. 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 manual wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve the manual wheelchair base and leg rest (K0195RR, K0001RR).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Renflexis.
You asked the Plan to pre-approve Renflexis. You say that the requested Renflexis is medically necessary. The
Plan denied your request. The Plan says that the enrollee does not meet criteria for Renflexis.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA approved
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Renflexis. Our reviewer says that the
enrollee meets criteria for Renflexis. Our physician reviewer found the enrollee is diagnosed with Pyoderma
Gangrenosum. The requested use of Renflexis is supported by multiple major drug compendia, such as
Ulcerative pyoderma gangrenosum in inflammatory bowel disease (Motta I, Perricone G.Lancet Gastroenterol
Hepatol. 2019 Jun;4(6):488. doi: 10.1016/S2468-1253(19)30038-X.PMID: 31070128) and Clinical features
and treatment of peristomal pyoderma gangrenosum (Hughes AP, Jackson JM, Callen JP.JAMA. 2000 Sep
27;284(12):1546-8. doi: 10.1001/jama.284.12.1546.PMID: 11000649).
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Renflexis have been met. Therefore, we decided that the Plan has to preapprove
Renflexis.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D2393, D1110, D0120) received from
the opt-out provider.
You asked the Plan to pay for the dental services. You say that you did not know the provider opted out of
Original Medicare. The Plan denied your request. The Plan says you may see any licensed dental provider who
accepts Medicare patients in the U.S. and has not opted out of Original 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. The Plan has submitted evidence that the provider in this case has
opted out of Original Medicare. Therefore, we decided that the Plan does not have to pay for the dental services
(D2393, D1110, D0120) received from the opt-out provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns on teeth #'s 8 and 9.
You asked the Plan to pre-approve the crowns. You say that the enrollee needs crowns on teeth #'s 8 and 9. The
Plan denied your request. The Plan says the documentation provided does not demonstrate that there is
pathologic destruction to more than 50% of the incisal edge (with incisal angle involvement) and 4 or more
surfaces of the tooth.
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 crowns
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 crowns. Our reviewer says that the
documentation provided does not meet the criteria for coverage for crowns for teeth #'s 8 and 9. Our physician
reviewer found the radiograph submitted shows the presence of crowns on teeth #'s 8 and 9. No preoperative
radiographs were included. Our reviewer also found that preoperative radiographs are required to determine the
need for the service.
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 crowns have not been met. Therefore, we decided that the Plan does not
have to pre-approve crowns on teeth #'s 8 and 9.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on December 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that the service is medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 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 office visit provided on December 23, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial lower denture (D5214).
You asked the Plan to pre-approve the partial lower denture. You say that the services were denied due to needing other work done first. You say that there were no specifics on what work needed to be done. The Plan denied your request. The Plan says the partial lower denture is not medically necessary. The Plan says that there is decay or apical pathosis present on teeth # 31 and 32.
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 partial lower denture 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 partial lower denture. Our reviewer says that the partial lower denture is not medically necessary. Our physician reviewer found there is no verification that there is no existing partial lower denture though the insurance denial indicated there had been a prior appliance within the past 5 years. The reviewer found that the bone levels appear to be adequate for a partial denture, however the endodontic status of tooth # 32 is unclear from the panoramic x-ray. The reviewer found that confirmation of endodontic status of the abutment teeth is required as well as confirmation that there is no recent lower partial denture. Based on the provided documentation, the reviewer found that there is no current medical necessity for the requested partial lower denture.
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 partial lower denture have not been met. Therefore, we decided that the Plan does not have to pre-approve a partial lower denture (D5214).