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

We decided that the Plan does not have to pre-approve relocation of mouth tissue to gum surface (CPT code 41899 x8), for the enrollee.
You asked the Plan to pre-approve the dental services. You say that if the enrollee does not get procedure will cause infection throughout the mouth, the enrollee loses all of their teeth or even death. The Plan denied your
request. The Plan says extraction of infected and decayed teeth is not a covered benefit under Medicare unless the extraction is done to prepare the jaw for radiation treatment for neoplastic cancer disease.
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. Extraction of infected and decayed teeth are not a covered benefit under Medicare unless the extraction is done to prepare the jaw for radiation treatment for neoplastic cancer disease. The supplemental dental benefit does not cover procedures for dental extractions for any diagnosis other than radiation treatments to prepare the jaw for radiation. Therefore, we decided that the Plan does not have to pre-approve relocation of mouth tissue to gum surface (CPT code 41899 x8), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 18, 2020 by an out of network (OON) provider.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-network provider without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The referring provider 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 laboratory services provided on June 18, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be provided by an OON provider.

You asked the Plan to pre-approve office visits to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.

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 OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit, arthrocentesis and hymovis injection provided by an out-of-network provider on February 10, 2020.

You asked the Plan to pay for the office visit, arthrocentesis and hymovis injection. You say that you were at the front desk when they called for approval. You say that the bill remains unpaid even though your premiums were paid, and you are appealing the decision not to pay the claim. The Plan denied your request. The Plan says prior authorization was not obtained for non-urgent 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 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, arthrocentesis and hymovis injection provided by an out-of-network provider on February 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81226, 81230, 81231, 81240, 81241, 81328, 81408) provided July 28, 2020.
You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The Plan denied your request. The Plan says the tests performed are not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment testing / panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease.
We looked at the file and Medicare rules. The tests performed are non-covered. 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 lab services (81226, 81230, 81231, 81240, 81241, 81328, 81408) provided July 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 8, 2021. You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing is 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 test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on February 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-one.

You asked the Plan to pre-approve Gel-one. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via intra-articular injections of hyaluronic preparations will be considered medically reasonable and necessary 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 Gel-one. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no imaging that documents osteoarthritis in your left knee. Therefore, you do not meet the requirements of the LCD and the request is considered 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 Gel-one have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-one.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp.

You asked the Plan to pre-approve the Aranesp. You say that the member is a kidney transplant recipient and has anemia due to chronic kidney disease. The Plan denied your request. The Plan says there is not a medical need for the use of Aranesp.

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 the Aranesp. Our reviewer says that the member does not meet criteria for Aranesp for anemia of chronic kidney disease. Our physician reviewer found the member does not have advanced kidney disease and does not have anemia. 

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 Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider 
on March 16, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. 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 the services provided to you by an out-of-network provider on 
March 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from
March 10, 2021, to March 16, 2021.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that this was supposed to be
a 2-day inpatient admission, after which you were to be discharged to another facility. You say you had to stay
in the hospital longer because the Plan took too long to approve the next facility. The Plan denied your request.
The Plan says this copayment 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 a $325
copayment for each of the first six days of a Medicare-covered inpatient stay.
You have been asked to pay a $1,950 copayment for a six-day inpatient hospital stay. 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 inpatient hospital stay provided from March 10, 2021, to March 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on February 21, 2021, by an out of network (OON) provider.

You asked the Plan to pay for an office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says services were provided by an out-of-network provider without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 an office visit (99214) provided on February 21, 2021, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nerve treatment on bicuspid tooth # 12 and bicuspid 
tooth nerve canal repair on tooth #4. 
 
You asked the Plan to pre-approve nerve treatment on bicuspid tooth #12 and bicuspid tooth nerve canal repair 
on tooth #4. You say that the services are necessary. The Plan denied your request. The Plan says the requested 
services are 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 
nerve treatment on bicuspid tooth # 12 and bicuspid tooth nerve canal repair on tooth #4.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for wheelchair services provided on November 23, 2020 by an
out of network (OON) provider.

You asked the Plan to pay for wheelchair services. You say that the member is deceased. You say that you
would like this claim paid. The Plan denied your request. The Plan says prior authorization was not obtained
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 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 wheelchair services provided on November 23,
2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
You asked the Plan to pre-approve RFA. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 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 RFA. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the clinical value and effectiveness of radiofrequency ablation to the (sacroiliac) SI joint in the setting of SI joint dysfunction has not been demonstrated in the peer-reviewed literature. There is no documentation of the provider requesting a RFA procedure of the SI joint. The review has determined that the items/services at issue in this case are 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 RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a telehealth visit (99203) provided on March 9, 2021.

You asked the Plan to pay for the telehealth visit. You say that the services were medically necessary. The Plan denied your request. The Plan says there were 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 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 service at issue. 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 telehealth visit (99203) provided on March 9, 2021.
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 physical therapy services. You say that you have an established relationship with this provider. The Plan denied your request. The Plan says the provider you requested is not part of your primary care physician's network. You must receive your care from a network provider. In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan's network) will not be covered.

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Remicade. 
 
You asked the Plan to pre-approve Remicade. You say that the medication is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Remicade. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the review has determined that the 
documentation does not support that the Remicade is medically reasonable and necessary for the enrollee. The 
documentation does not support that the Remicade is safe and effective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Remicade have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Remicade.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory tests (80048, 81003) provided on December 30, 2020.

You asked the Plan to waive the copayment for laboratory tests. You say that you called the Plan and was informed that a copayment should not have been assessed. The Plan denied your request. The Plan says the copayment you are being charged is correct. The Plan also says that you called inquiring about your cost share after the date of service in question.

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 $10 copayment for outpatient diagnostic tests and therapeutic services and supplies.

You have been asked to pay a $10 copayment for laboratory tests. The EOC confirms $10 is the required copayment for this service. Laboratory tests fall 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 laboratory tests (80048, 81003) provided on December 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride excluding varnish, first
intraoral periapical x-ray, crowns, core buildups, including any pins when required, endodontic therapy, and
resin-based composites provided from January 11, 2021, to March 31, 2021.

You asked the Plan to pay for the topical application of fluoride, first intraoral periapical x-ray, crowns, core
buildups, endodontic therapy, and resin-based composites. You say that these services were needed due to
results from radiation and chemotherapy treatments.

The Plan denied your request. The Plan says the topical application of fluoride, first intraoral periapical x-rays,
crowns, core buildups, and endodontic therapy are not covered services. The Plan also says that your benefits
for resin-based composites have been satisfied and the frequency limitation has been exceeded.

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 topical application of fluoride
excluding varnish, first intraoral periapical x-ray, crown, core buildup, including any pins when required, and
endodontic therapy are not among those covered under this benefit. The contract says that resin-based
composite is limited to one procedure per calendar year. The record shows that you received a resin-based
composite which was covered by the Plan, and your resin-based composites benefit has been exhausted.
Therefore, we decided that the Plan does not have to pay for the topical application of fluoride excluding
varnish, first intraoral periapical x-ray, crowns, core buildups, including any pins when required, endodontic
therapy, and resin-based composites provided from January 11, 2021, to March 31, 2021.