Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe bitewings -four radiographic images with dental code D0274 provided on August 31, 2020.You asked the Plan to pay fordental code D0274. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. ThePlan says you have exceeded the limit for these 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.We looked at the file, the Plan's contract and Medicare rules. The Plan's contract says that enrollees are covered once per plan year for dental codes D0270, D0272, D0273, D0274, and D0277. The file shows that the Plan paid for dental code D0270 provided to you on July 7, 2020. This means that you have reached your benefit limit for these x-rays for the 2020 Plan year.Therefore, we decided that the Plan does not have to pay forthe bitewings -four radiographic images with dental code D0274 provided on August 31, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve inpatient hospital admission for total hip arthroplasty. You asked the Plan to pre-approve inpatient status. You say that per risk stratification, the enrollee is expected to require medically necessary inpatient care. The Plan denied your request. The Plan says that the denial of authorization for inpatient status is correct, because this surgery can be performed in outpatient status with post-operative inpatient admission if needed or admission to inpatient rehabilitation facility (IRF) or skilled nursing facility (SNF) if needed. The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 inpatient status. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has sufficient comorbid conditions that the total hip arthroplasty needs to be performed as inpatient status. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient status have been met. Therefore, we decided that the Plan has to pre-approve inpatient hospital admission for total hip arthroplasty.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home infusion therapy rendered on April 30, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe home infusion therapy rendered on April 30, 2020.Benefits for these servicesmay be available under Medicare Part D.Contactthe 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 pay forthe Collagenase Santyl provided from August 20, 2020, to August 27, 2020.You asked the Plan to pay forthe Collagenase Santyl. You say that your doctor prescribed you another drug that you did nottolerate. You also say that you continued using your original prescription for the Collagenase Santyl.The Plan denied your request. The Plan says self-administered drugs are not covered in the outpatient setting under Medicare Part B per Medicare Guidelines.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 pay forthe Collagenase Santyl provided from August 20, 2020, to August 27, 2020.Benefits for the Collagenase Santylmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pay fora CT scan (CPT 70450) provided to the enrollee on July 8, 2020.You asked the Planto pay forthe scan. You say that this should be paid for.The Plandenied your request. The Plansaysthis is an exact duplicate claim/service.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, the CPT Code Manual definition of code 70450 is "Computed tomography, head or brain."We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan wascorrect in denying the request to pay for the scan. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found a review of the records shows a single CT of the brain. CPT 70450 was done on 7/8/20 and read by the doctor at 6:57. An amended report was then issued a few minutes later. This amended report does not qualify for a second reimbursement. There is no evidence of a separate second CT of the brain was done.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 scan have not been met.Therefore, we decided that the Plandoes not haveto pay fora CT scan (CPT 70450) provided to the enrollee on July 8, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operated vehicle.
You asked the Plan to pre-approve the vehicle. You say that this is medically necessary. The Plan denied your
request. The Plan says this is being requested for use in the community.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 vehicle. Our reviewer says that the
requested vehicle is not medically reasonable or necessary. Our physician reviewer found the documentation
does not reveal that you have a personal mobility deficit that impairs participation in MRADLs in the home.
The documentation reveals that your mobility deficit is able to be helped by a walker. This wheelchair is not
needed to significantly improve ADL performance. This is not needed outside of community use.
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 vehicle have not been met. Therefore, we decided that the Plan does not
have to pre-approve a power operated vehicle
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered.

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 procedure code 95999 is not supported.

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, the CPT Code Manual definition of code 95999 is unlisted neurological or neuromuscular diagnostic procedure.

We find that CPT code 95999 is not supported in the medical record. Specifically, the file shows that Train of Four testing was performed and there is a more appropriate code for these services. 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 pay for the testing services rendered.
Appeal type: Outpatient Therapies
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in the Medicare Managed Care Manual, Chapter 1, Section 20.2.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan 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 enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information on page 12 of the 2020 Evidence of Coverage (EOC)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe preventive procedure, comprehensive oral evaluation, prophylaxis, and additional intraoral periapical x-ray provided on September 3, 2020 by an OON provider.You asked the Plan to pay forthe preventive procedure, comprehensive oral evaluation, prophylaxis, and additional intraoral periapical x-ray. You say that you were told that this provider was in-network with your plan.The Plan denied your request. The Plan says you were correctly charged a 50% coinsurance for the comprehensive oral evaluation, prophylaxis, bitewing x-rays, and two intraoral periapical x-rays. The Plan also says that unspecified preventive procedure for personal protective equipment is not a covered benefit, and benefits for the intraoral periapical x-ray 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, unspecified preventive procedure is not among those covered under this benefit. The contract clearly states that you are responsible for a 50% coinsurance for services rendered OON, and your share of the cost may be higher if you use an OON dentist. The Plan contract also says that intraoral x-rays are limited to one procedure per calendar year. The record shows that you received 3 intraoral periapical x-rays on September 3, 2020, two of which were covered by the Plan, and your intraoral x-rays benefit had been exhausted.Therefore, we decided that the Plan does not have to pay forthe preventive procedure, comprehensive oral evaluation, prophylaxis, and additional intraoral periapical x-ray provided on September 3, 2020 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvesurgery to place a Vertiflex Superion device (CPT Codes: 22869 and 22870).You asked the Plan to pre-approvethe services. You say that the services are necessary.The Plan denied your request. The Plan says the services are considered experimental/investigational and are not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer is experimental. 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 the services have not been met.Therefore, we decided that the Plan does not have to pre-approvesurgery to place a Vertiflex Superion device (CPT Codes: 22869 and 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe manual wheelchair (K0007) provided on August 8, 2020.You asked the Plan to waive the coinsurance forthe manual wheelchair. You say that you were not expecting to be billed a coinsurance amount for each month of the rental for the wheelchair.The Plan denied your request. The Plan says a 20% coinsurance is required for durable medical equipment.The rules say a Plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for durable medical equipment (DME) and related supplies. You have been asked to pay coinsurance for the manual wheelchair. A manual wheelchair falls within the durable medical equipment (DME) and related supplies benefit category. The amount you have been asked to pay is equalto or less than 20% of the monthly rental cost for the wheelchair. 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 thePlan.Therefore, we decided that the Plan does not have to waive the coinsurance forthe manual wheelchair (K0007) provided on August 8, 2020.Please note that pages 74-75 of the Plan's 2020 EOC also state that, "The total rental price cannot exceed the purchase price, if applicable." In your request you indicated that you did not expect to be billed monthly for a rental, and instead assumed that the Plan had purchased the chair. The cost of a monthly rental is lower than the cost of a purchase, and per the Plan's EOC the total price for the rental will not be more than the purchase price. While you are expected to pay a coinsurance for each month of the rental, your total payment responsibility should not exceed the cost of a purchased wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay forvitamin injections as part of a naturopathy visit received on May 20, 2020.You asked the Planto pay forthe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services. The rules say that Medicare does not cover vitamin injections.Medicare does not cover vitamin injections.Therefore, we decided that the Plandoes not haveto pay forvitamin injections as part of a naturopathy visit received on May 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe eye surgery provided on April 20, 2020.You asked the Plan to waive the copayment forthe eye surgery. You say that you had an unsuccessful left eye surgery to replace an intraocular (I/O) lens that had shifted out of position. You state the doctors declared the repaired lens had not stayed in place, and another surgery was necessary to remove the I/O lens.The Plan denied your request. The Plan says outcomes of medical care are not guaranteed and are dependent on multiplefactors. The Plan states complications are unfortunate but your copayment is due regardless.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received the eye surgery on April 20, 2020. You are asked to paya $350 copayment for the services. Your EOC states that enrollees must pay a $350 for each visit to an outpatient hospital facility. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is acontractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe eye surgery provided on April 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral/facial photographic image, preventive procedure,
four extractions, four pontics, and two retainer crowns provided on May 21, 2020 by an OON provider.
You asked the Plan to pay for the 2D oral/facial photographic image, preventive procedure, extractions,
pontics, and retainer crowns. You say that these services were provided due to an infection, which should be
covered under the enrollee's medical benefit. You also say that these services were an emergency. The Plan
denied your request. The Plan says these services were rendered by a non-participating 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.
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 2D
oral/facial photographic image, preventive procedure, four extractions, four pontics, and two retainer crowns
provided on May 21, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive oral evaluation, bitewing x-ray, and prophylaxis provided on August 25, 2020 by an OON provider.You asked the Plan to pay forthe comprehensive oral evaluation, bitewing x-ray, and prophylaxis. You say that the benefit package that you received says dental is covered 100% both in-network and OON.The Plan denied your request. The Plan says the total $142.00 amount applied correctly as member liability. The Plan also says that cost sharing is a contractual obligation under the Plan and cannot be waived.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, you are responsible for the difference between the billed amount and allowed amount.Therefore, we decided that the Plan does not have to pay forthe comprehensive oral evaluation, bitewing x-ray, and prophylaxis provided on August 25, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation, preventive
procedure, sales tax, and first intraoral periapical x-ray provided on June 9, 2020.
You asked the Plan to pay for the comprehensive periodontal evaluation, preventive procedure, sales tax, and
first intraoral periapical x-ray. You say that you were in pain and these procedures relieved you of this pain.
You also say that other dental offices were closed due to COVID-19, and you had no option but to accept this
provider's treatment. The Plan denied your request. The Plan says comprehensive periodontal evaluation is not
a covered benefit, and the periapical x-ray exceeded the frequency limitation. The Plan also says that a separate
fee for infection control and sales tax is not covered under your plan.
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 comprehensive periodontal
evaluation, preventive procedure, and sales tax are not among those covered under this benefit. The contract
also clearly states that you are limited to four periapical x-rays in a twelve-month period. The record shows that
you received two periapical x-rays on October 15, 2019, one periapical x-ray on November 16, 2019, and one
periapical x-ray to a different provider on June 9, 2020, and your periapical x-rays benefit had been exhausted.
Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation,
preventive procedure, sales tax, and first intraoral periapical x-ray provided on June 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydroxyzine Pamoate.
You asked the Plan to pre-approve Hydroxyzine Pamoate. 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 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 Hydroxyzine Pamoate.
Benefits for Hydroxyzine Pamoate 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-approveSynvisc One.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic left knee pain due to osteoarthritis. She has not tried and failed the Plan's required drugs of Euflexa, Supartz FX, Durolane, or Gelysn-3. The records do not support that the required drugs would be contraindicated or less effective; therefore, Synvisc One 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-approveSynvisc One.