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

We decided that the Plan does not have to pay for the office visit provided on September 22, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.

Therefore, we decided that the Plan does not have to pay for the office visit provided on September 22, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve replacement of semi-precision or precision attachment (male or female component) of implant/abutment supported prosthesis, per attachment (D6091), and bone graft at time of implant placement (D6104) for teeth 11 and 6.

You asked the Plan to pre-approve replacement of semi-precision or precision attachment and bone graft. You say that the services are medically necessary. The Plan denied your request. The Plan says these services are not covered under your 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 pre-approve replacement of semi-precision or precision attachment (male or female component) of implant/abutment supported prosthesis, per attachment (D6091), and bone graft at time of implant placement (D6104) for teeth 11 and 6.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve a home ventilator to be provided by an OON provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network providers available to the enrollee that can provide the item that is being requested.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a home ventilator to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).

You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are experimental/investigational.

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 a Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Food and Drug Administration has stated that the Vertiflex device is indicated to treat skeletally mature patients suffering from pain, numbness, and/or cramping in the legs (neurogenic intermittent claudication) secondary to a diagnosis of moderate lumbar spinal stenosis, with or without Grade 1 spondylolisthesis. In this case, the enrollee has low back and hip pain. Imaging studies demonstrate less than moderate spinal stenosis.

The elements of the coverage criteria are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (J9271).

You asked the Plan to pre-approve Keytruda. You say that the drug is medically necessary. The Plan denied
your request. The Plan says you are not using this drug for a medically accepted indication, and therefore, it is
not covered under your medical benefit.

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 Keytruda. Our reviewer says that the
use of this drug in this patient is not reasonable or medically necessary. Our physician reviewer found there is
limited clinical data about the efficacy of switching the administration of this drug and that more data is
needed.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Keytruda have not been met. Because you are not using this drug for a
medically accepted indication, it is not covered under your medical benefit. Therefore, we decided that the Plan
does not have to pre-approve Keytruda (J9271).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740) and removal of residual tooth roots (D7250).

You asked the Plan to pre-approve the crown and root extraction. You say that these services are necessary. The Plan denied your request. The Plan says these services are not covered by 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. Therefore, we decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740) and removal of residual tooth roots (D7250).
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 IRF services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

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 there is not a reasonable expectation that this patient 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation with a provider other than the requesting provider (D9310), a bone replacement graft (D7953), a core buildup (D2950) for tooth #29 and a crown (D2751) for tooth #29.

You asked the Plan to pre-approve the dental services. You say that these services are necessary, and you cannot afford them. The Plan denied your request. The Plan says a consultation with a provider other than the requesting provider and bone replacement graft are not covered by your dental benefits. A core buildup and crown are covered services, however you had both a core buildup and crown provided for this tooth in 2018. These services can only be covered once per tooth every 5 plan years. Therefore, the benefit for these services for tooth #29 have been met and payment cannot be made.

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 or are requested in a frequency that exceeds what is covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a consultation with a provider other than the requesting provider (D9310), a bone replacement graft (D7953), a core buildup (D2950) for tooth #29 and a crown (D2751) for tooth #29.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture (D5120).

You asked the Plan to pre-approve the complete maxillary denture and complete mandibular denture. You say that you would like these dentures to be approved for coverage. The Plan denied your request. The Plan says these services are not covered benefits. The Plan also says that you have not signed up for the comprehensive 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. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the subsequent hospital care provided from February 23, 2021, to February 25, 2021.

You asked the Plan to waive the co-payment for the subsequent hospital care. You say that you would like the Plan to settle this claim. 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 co-payment for physician services while inpatient at an out-of-network hospital.

You have been asked to pay a $0 co-payment for the subsequent hospital care. The subsequent hospital care falls within the "Inpatient hospital care" 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 the subsequent hospital care provided from February 23, 2021, to February 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an excision of benign lesion up to 1.25 cm (centimeter) (D7410).

You asked the Plan to pre-approve the dental service. You say that this service is medically necessary. The Plan denied your request. The Plan says excision of benign lesion up to 1.25 cm is not listed as a covered service.

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 an excision of benign lesion up to 1.25 cm (centimeter) (D7410).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lidocaine patches.

You asked the Plan to pre-approve Lidocaine patches. You say that this should be covered. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.

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 Lidocaine patches.

Benefits for Lidocaine patches 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an alveoloplasty in conjunction with extractions for one to three teeth per quadrant (D7311).

You asked the Plan to pre-approve the alveoloplasty. You say that this service is medically necessary. The Plan denied your request. The Plan says this service is not covered by the Plan's 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. Therefore, we decided that the Plan does not have to pre-approve an alveoloplasty in conjunction with extractions for one to three teeth per quadrant (D7311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve osseus surgery (D4261) for teeth 17, 24, 25, 32, 9, 16, 1, and 8 and bone replacement graft (D4263) for teeth 2, 14, 19, and 30.

You asked the Plan to pre-approve osseus surgery and bone replacement graft. You say that your dentist has deemed these services necessary, and you are concerned that you will have further issues if the services are denied. The Plan denied your request. The Plan says these services are not covered under your 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 pre-approve osseus surgery (D4261) for teeth 17, 24, 25, 32, 9, 16, 1, and 8 and bone replacement graft (D4263) for teeth 2, 14, 19, and 30.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services rendered on January 4, 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 provider type is not covered.

The Plan must follow Medicare rules. The rules say that only a doctorate or masters level clinical social worker is able to provide mental health services. 

We looked at the file and Medicare rules. The file shows that the provider is not a doctorate or masters level clinical social worker. 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 outpatient mental health services rendered on January 4, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and care.

You asked the Plan to pre-approve SNF admission and care. You say that the service is medically necessary
and that you have nowhere else to go and are unable to care for yourself. The Plan denied your request. The
Plan says the service is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 SNF admission and care. Our reviewer
says that daily skilled services are not necessary. Our physician reviewer found the beneficiary does not require
daily skilled nursing or therapy services and does not meet severity of illness or intensity criteria for an
inpatient basis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF admission and care have not been met. Specifically, medically necessary
services can be obtained at a lower level of care. This means admission into a SNF is not medically necessary.
Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and
care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation (D9310), first 15 minutes of intravenous moderate (conscious) sedation/analgesia (D9239), and three subsequent 15 minute increments of intravenous moderate (conscious) sedation/analgesia (D9243 x3).

You asked the Plan to pre-approve the consultation and intravenous moderate (conscious) sedation/analgesia services. You say that you need the sedation to be approved for the surgery. The Plan denied your request. The Plan says these services 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, 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 a consultation (D9310), first 15 minutes of intravenous moderate (conscious) sedation/analgesia (D9239), and three subsequent 15 minute increments of intravenous moderate (conscious) sedation/analgesia (D9243 x3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup (D2950) provided on January 12, 2021.

You asked the Plan to pay for the core buildup. You say that you were not told these services were not covered before they were provided. You are upset with the lack of communication from the provider's office and the timeliness of their billing. The Plan denied your request. The Plan says this service is not covered by 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 core buildup (D2950) provided on January 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services rendered from November 23, 2020 to December 6, 2020.

You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the 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 $200 copayment per day for days 1-6 for in-network inpatient hospital care.

Review of the file shows that you received inpatient hospital services from November 23, 2020 to December 6, 2020. You have been asked to pay a $200 copayment per day for days 1-6 for these services, for a total of $1,200. These services fall within the in-network inpatient hospital care 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 inpatient hospital services rendered from November 23, 2020 to December 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for physician services or coinsurance for the injections provided from January 16, 2020, to December 21, 2020.

You asked the Plan to waive the copayments for the physician services and the coinsurance for the injections. You say that the cost share charges are incorrect. The Plan denied your request. The Plan says you were charged this cost share 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 $35 copayment for Physician Services and 20% coinsurance for Medicare Part B Prescription Drugs.

You have been asked to pay a $35 copayment for the physician services and 20% coinsurance for the injections. The physician services fall within the Physician Services and the injections fall within the Medicare Part B Prescription Drugs 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 copayments for physician services or the coinsurance for the injections provided from January 16, 2020, to December 21, 2020.