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

We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869).
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says this service 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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the Superion device is experimental. More research is needed to show safety and efficacy of the device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the crown - porcelain/ceramic (D2740 x4) received January 13, 2021.

You asked the Plan to pay an additional amount for the crowns. You say that you are on a limited income and cannot pay the balance. The Plan denied your request. The Plan says your dental benefit is limited to $3,000 annually for covered services.

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 Plan offers a $3,000 benefit allowance for covered dental services in the 2021 calendar year. The Plan has submitted evidence that you exhausted this benefit allowance in the requested claim. You are responsible for any amount billed by the provider over the Plan's $3,000 benefit allowance. Therefore, we decided that the Plan does not have to pay an additional amount for the crown - porcelain/ceramic (D2740 x4) received January 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the operating room services provided October 28, 2020
You asked the Plan to waive the copayment for the operating room services. You say that you had met your maximum out of pocket, and you feel that you should not be responsible for the $350 balance The Plan denied your request. The Plan says claims were reprocessed, and the copayment was applied, and this amount was then applied to your maximum out of pocket, resulting in you meeting the maximum out of pocket with the inclusion of this claim.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $350 copayment at an outpatient hospital. You have been asked to pay $350 copayment for the operating room services. The operating room services falls within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 operating room services provided October 28, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an abutment supported porcelain and metal crown (D6059) provided on February 1, 2021.
You asked the Plan to pay for the abutment supported crown. You say that the Plan covers crowns, so this service should be covered. The Plan denied your request. The Plan says abutment supported crowns are not covered under your 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, the requested items or services are not among those covered under this benefit. Procedures are classified by unique codes that differentiate between specific items and services. The Plan does list some crowns as covered services in the contract, however the specific code (D6059) for an abutment supported porcelain fused to metal crown is not listed as covered. Therefore, we decided that the Plan does not have to pay for an abutment supported porcelain and metal crown (D6059) provided on February 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft - retained natural tooth - first site in quadrant (D4263) and guided tissue regeneration - resorbable barrier, per site (D4266) provided January 8, 2021.
You asked the Plan to pay for the bone replacement graft and guided tissue regeneration. You say that you were not informed of the cost of the procedures. The Plan denied your request. The Plan says the services are not covered under your dental 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 pay for the bone replacement graft - retained natural tooth - first site in quadrant (D4263) and guided tissue regeneration - resorbable barrier, per site (D4266) provided January 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vraylar.

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 self-administered drugs are not covered.

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-approve Vraylar.

Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zirabev.

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 the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 

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 not medically necessary. Our physician reviewer found the enrollee has metastatic hepatocellular carcinoma. Bevacizumab and atezolizumab are FDA approved and a standard of care for 1st line treatment of advanced hepatocellular cancer. The enrollee has had at least two prior lines of systemic therapy and would not meet coverage criteria. The service is not reasonable or 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 not been met. Therefore, we decided that the Plan does not have to pre-approve Zirabev.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wheelchair repair (E1399).

You asked the Plan to pay for the wheelchair repair. You say that you would like reconsideration because your wheelchair needs repairs. The Plan denied your request. The Plan says the clinical information does not show that the requested repair of the manual wheelchair is required to complete mobility related activities of daily living.

The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the wheelchair repair have not been met. Specifically, the documentation submitted does not include any medical records to verify if Medicare coverage criteria have been met. Of note, the record shows that the Plan made multiple attempts to obtain clinical information. Therefore, we decided that the Plan does not have to pay for the wheelchair repair (E1399).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on September 29, 2020.
You asked the Plan to pay for the laboratory service. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for laboratory services provided on September 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the interrogation device evaluation provided on January 28, 2021.
You asked the Plan to waive the copayment for the interrogation device evaluation. You say that you were not informed there would be a copayment. You say that you would have declined the insertion if you knew there was a copayment involved. The Plan denied your request. The Plan says the copayment 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 $35 for each outpatient x-ray, diagnostic procedure & test. You have been asked to pay $28.46, which is less than the standard $35 copayment for the interrogation device evaluation. The interrogation device evaluation falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the interrogation device evaluation provided on January 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on January 20, 2021.
You asked the Plan to pay for the office visit. You say that there is no other doctor with the qualifications, and he can control your condition. The Plan denied your request. The Plan says the out-of-network services were not authorized, and in-network providers were available.
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 office visit provided by an out-of-network provider on January 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve replacement of prosthetic leg with an advanced microprocessor knee-shin system and advanced foot.

You asked the Plan to pre-approve replacement of prosthetic leg with advanced features. You say that the enrollee meets the medical policy criteria for coverage of a microprocessor knee and foot per LCD L33787 and the proposed services are medically necessary. The Plan denied your request. The Plan says the enrollee's current microprocessor knee and foot is three years old. There is no documentation that the existing knee unit and foot are not in working condition. The records provided do not support the criteria for replacement.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules also say replacement of items due to irreparable wear takes into consideration the Reasonable Useful Lifetime (RUL) of the item. The RUL of DME is determined through program instructions. In the absence of program instructions, carriers may determine the RUL, but in no case can it be less than 5 years. You can find this rule in Local Coverage Article: Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426). 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of replacement of prosthetic leg with advanced features have not been met. Therefore, we decided that the Plan does not have to pre-approve replacement of prosthetic leg with an advanced microprocessor knee-shin system and advanced foot.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341 x4).

You asked the Plan to pre-approve periodontal scaling and root planing. You say that the service at issue should be a covered benefit. The Plan denied your request. The Plan says the service at issue 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 periodontal scaling and root planing (D4341 x4).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray (71045) provided on November 5, 2020.
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration because the member had multiple exams on the same date of service. The Plan denied your request. The Plan says CPT code 71045 is bundled to another service billed on the same day by the same physician or a physician of the same specialty in the same group, which is considered the same provider.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code the chest x-ray has a bundled relationship with code 32557 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray (71045) provided on November 5, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for x-rays (73502) provided January 4, 2021.

You asked the Plan to waive the co-payment for the x-rays. You say that the x-rays had to be re-taken because
ones taken in December 2020 were not taken correctly. The co-payment should be waived due to this error. The
Plan denied your request. The Plan says the correct co-payment was applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20
co-payment for x-rays.

You have been asked to pay a $20 co-payment for the x-rays. The x-rays fall within the x-rays 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 co-payment for x-rays (73502) provided January 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for out-of-network physical therapy visits.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are network providers available.
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 for out-of-network physical therapy visits.
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 it would not be safe for you to go another 30 days without the needed rehabilitation. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.

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 require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in - and benefit from - the intensive rehabilitation therapy program provided in an IRF.

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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.
You asked the Plan to pre-approve the physical therapy services. The Plan denied your request. The Plan says with limited exceptions, while a member of the plan, the member must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the member is out of the area), out-of-area dialysis services, and cases in which the plan authorizes the use of out-of-network providers.
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 services to be provided by the requested out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve MRI. You say that you need the service to be completed at this facility. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the plan and you can receive this MRI from 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 Magnetic Resonance Imaging (MRI) to be provided by an out of network (OON) provider.