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

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and an intraoral
complete series of radiographic images (D0210) provided on February 8, 2021.
You asked the Plan to pay for a comprehensive oral evaluation, and an intraoral complete series of radiographic
images. You say that The Plan denied your request. The Plan says you are not covered for these services when
seen by an out-of-network provider.
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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of a comprehensive oral evaluation, and an intraoral complete series of radiographic images have not
been met. Specifically, services were provided by an out-of-network provider without prior authorization.
The Plan has contracted providers available to provide these services. We found no exception that would
require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a
comprehensive oral evaluation (D0150), and an intraoral complete series of radiographic images (D0210)
provided on February 8, 2021.
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 this medication is medically necessary. The Plan denied your request. The Plan says the enrollee has not tried and failed the required drugs, Monovisc and Orthovisc. The Plan also says that the step therapy criteria has not been met.
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 provided documentation
does not indicate that the enrollee has trialed viscosupplemental treatments such as Orthovisc and Monovisc.
The reviewer found that the Plan's step therapy rules require 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 Synvisc is not 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 file does not indicate that the
enrollee has tried and failed the required drugs. Therefore, we decided that the Plan does not have to preapprove
Synvisc (J7325).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hip replacement surgery provided from August 17, 2020 to August 18, 2020.
You asked the Plan to waive the copayment for the hip replacement surgery. You say that you are appealing because you feel a mistake was made at the doctor's office. The Plan denied your request. The Plan says the claim originally had denied charges but has been reprocessed. 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 $250 copayment for each outpatient surgery and/or services at an ambulatory center or outpatient hospital facility.
You have been asked to pay a $250 copayment for the hip replacement surgery. The hip replacement surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical center" 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 hip replacement surgery provided from August 17, 2020 to August 18, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a repeat epidural steroid injection (ESI).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a repeat ESI is covered when specific criteria are met. 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 services are medically necessary. Our physician reviewer found you have a diagnosis of lumbar radiculopathy. You had an ESI two months ago that provided 80 percent pain relief for two months. You had a trial of physical therapy and magnetic resonance imaging (MRI) on April 19, 2019 that showed multi-level pathology. The criteria for coverage for a repeat ESI are met and the services are therefore reasonable and medically 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 these services have been met. Therefore, we decided that the Plan has to pre-approve a repeat epidural steroid injection (ESI).
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the initial hospital care (99221) and subsequent hospital care (99231) provided October 11, 2020, and October 13, 2020.

You asked the Plan to waive the deductible for the hospital care. You say that you were told the services would be covered by your deductible. The Plan denied your request. The Plan says the services have been processed correctly and your cost has been applied to your deductible.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $500 deductible for which you must pay out-of-pocket before the Plan will pay their share for your covered medical services. 

The item or service you asked the Plan to waive the deductible for falls within the benefit category Inpatient hospital care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible for your covered medical services. This cost sharing is a contractual obligation that had not been met at the time the hospital care was received on October 11, 2020 to October 13, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the initial hospital care (99221) and subsequent hospital care (99231) provided October 11, 2020, and October 13, 2020.

Your complaint about potentially receiving misinformation from plan representatives and being unhappy with your policy is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that this medication is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed zoledronic acid. The Plan also says there is no indication zoledronic acid, would likely be less effective, and/or cause adverse effects for the enrollee.
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 Prolia. Our reviewer says that the requested drug, Prolia, is not medically necessary. Our physician reviewer found the Plan requires a trial of drug zoledronic acid before they will approve the requested drug. The reviewer found that the provided documentation does not support that the enrollee has tried and failed the required drug. The reviewer found that there is no documentation provided indicating that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that the step therapy criteria has 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 Prolia have not been met. Specifically, the reviewer found that the enrollee has not tried and failed the required drug. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on June 16, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.

We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records do not show that the specimen was collected in a laboratory setting. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on June 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on March 9, 2021 and April 12, 2021.
You asked the Plan to pay for the dental services. You say that you have been a patient of this dentist since 1999 and wish to remain with his office. You say that you are not comfortable going to a new dentist and want to stay his patient. The Plan denied your request. The Plan says services performed by an out-of-network provider 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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental services provided on March 9, 2021 and April 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telephone evaluation and management services provided on April 1, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the telephone evaluation and management services. You say that the services were medically necessary and billed in error. The Plan denied your request. The Plan says the claim originally denied for not meet coding standards, but the services were not authorized.
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 telephone evaluation and management services provided on April 1, 2021 by an out-of-network (OON) provider.
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 admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an 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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee does not require services at the LTACH that are not available at the present setting where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan provided on March 17, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the CT scan. You say that an authorization is not required, and 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 a computed tomography (CT) scan provided on
March 17, 2021 by an out-of-network (OON) provider
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on March 17, 2021.
You asked the Plan to waive the copayment for the ambulance ride. You say that you were told there would be no cost because the hospital sent you home too soon. 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 $300 copayment for in-network Medicare-covered ground transportation service. You have been asked to pay a $300 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance services" benefit category. The record shows that for 2021, the ambulance copayment is not waived if you are admitted to the hospital for the same condition. 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 ambulance ride provided on March 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient hospital admission.

You asked the Plan to pre-approve acute inpatient hospital care. You say that you disagree with the denial. The Plan denied your request. The Plan says the inpatient level of care is not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee is planned for an elective total shoulder arthroplasty. She has a past medical history of hypertension, carotid atherosclerosis, congestive heart failure. She will need postoperative care assistance at home as she lives alone.

Based on the low risk procedure, there is no expectation that the enrollee will require hospital services that will likely cross two midnights. Post-surgical care does not require the inpatient level of care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient hospital admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the panoramic x-ray (D0330) provided on April 14, 2021.
You asked the Plan to pay for the dental services. You say that you have contacted the plan many times regarding an in network dentist. You say that you were sent a list. You say that most were not with the plan any longer or out of state. You also say that your only choice was to go out of network. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services performed out of network are not covered. The Plan also says that there are numerous in network providers in your area.
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 services performed out of
network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the panoramic x-ray (D0330) provided on April 14, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the trigger point injection provided on March 1, 2021.
You asked the Plan to pay for injection(s); single or multiple trigger point(s), 3 or more muscles (20553). You
say that the Plan should pay this claim. The Plan denied your request. The Plan says information provided at
the time of appeal does not support evidence based clinical criteria for the injection.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for injection(s); single or multiple trigger
point(s), 3 or more muscles (20553). Our reviewer says that the service was not considered medically
reasonable and necessary in this case. Our physician reviewer found there was no quantified estimation of
benefit from prior injections and no described dermatome or radicular pain pattern. There was no documented
trial of activity modification, home exercises, nonsteroidal anti-inflammatory drugs, physical therapy, or spinal
manipulation for six weeks or longer. There is no significant decrease in range of motion, strength or stability
sufficient to interfere with activities of daily living or having significant impact on school or job performance.
There was no documented comprehensive treatment plan with milestones and goals outlined. There was no
documented absence of other serious pathology (i.e. acute fracture, dislocation, ligament rupture, tumor,
arthritis, or infection). The review indicates that the injection was 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 injection(s); single or multiple trigger point(s), 3 or more muscles (20553) have
not been met. Therefore, we decided that the Plan does not have to pay for the trigger point injection provided
on March 1, 2021.