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

 
We decided that the Plan does not have to waive or reimburse the cost share for several claims for services 
provided on August 21, 2019, to October 9, 2019.  
 
You asked the Plan to waive or reimburse funds you believe were overpaid for services provided in 2019. You 
say that you believe you have overpaid the maximum out of pocket (MOOP) for 2019. The Plan denied your 
request. The Plan says the claims in question were reviewed. The Plans portion of the services in question have 
been paid for each service leaving your contractual copayments based on the Plan contract.  
 
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 in 2019 there was a 
maximum out of pocket of $4500. The Plan has provided claim and payment information for each service in 
question. Both the records and the Explanation of Benefits (that you would also have a copy of ) for each 
service clearly show the balance of the maximum out of pocket at the time of service. You have been asked to 
pay the correct amount for each service 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 or reimburse the cost share for several claims for services provided on August 21, 2019, to October 9, 
2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray, preventive procedure, 
crown, and core buildup, including any pins when required provided on September 8, 2020. 
 
You asked the Plan to pay for the first intraoral periapical x-ray, preventive procedure, crown, and core 
buildup. You say that you did not check your insurance plan to see what would be covered. You also say that 
you were experiencing discomfort, and wanted the tooth to be taken care of. 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 pay for the first 
intraoral periapical x-ray, preventive procedure, crown, and core buildup, including any pins when required 
provided on September 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and unspecified 
preventive procedure (D1999) provided on September 3, 2020. 
 
You asked the Plan to pay for the limited oral evaluation and unspecified preventive procedure. You say that 
these services were medically necessary. The Plan denied your request. The Plan says these services are not 
covered under your supplemental 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 pay for the 
limited oral evaluation (D0140) and unspecified preventive procedure (D1999) provided on September 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on August 7, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. 
The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the 
rendering facility is also out-of-network. 
 
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 physician services provided on August 7, 2020 by 
an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the admission to the skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission to the SNF. You say that you need SNF care. The Plan denied
your request. The Plan says rules for SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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 the admission to the SNF. Our reviewer
says that daily skilled services are not necessary. Our physician reviewer found while you have identifiable
skilled therapy service needs, you have no identifiable skilled nursing service needs. In addition, you do not
require skilled nursing or therapy services on a daily basis and do not meet severity of illness or intensity of
service criteria for an inpatient basis in a skilled nursing facility setting. 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 admission to the SNF have not been met. Therefore, we decided that the
Plan does not have to pre-approve the admission to the skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a porcelain crown on tooth #19 (D2470).
You asked the Plan to pre-approve a porcelain crown on tooth #19. You say that the services are necessary. The
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not
been met.
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 a porcelain crown on tooth #19. Our
reviewer says that the requested items/services are considered medically reasonable and necessary in this case.
Our physician reviewer found that the criteria for coverage for a crown for tooth #19 has been met. The
existing crown has been in place for more than ten years and is fractured.
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 porcelain crown on tooth #19 have been met. Therefore, we decided that the
Plan has to pre-approve a porcelain crown on tooth #19 (D2470).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pontics (D6240) for tooth #'s 2 and 4 and retainer
crowns (D6750) for tooth #'s 3 and 5.
You asked the Plan to pre-approve the pontics and retainer crowns. You say that you need a bridge. The Plan
denied your request. The Plan says these services are not medically necessary.
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. The Plan covers the pontics
and retainer crowns when the services are medically necessary and reasonable.
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 pontics and retainer crowns. Our
reviewer says that these services do not meet the Plan's coverage criteria. Our physician reviewer found the
reason for the denial was that the service is not a covered expense; posterior fixed bridges are not a covered
expense. Our reviewer found that your dental record and radiographs indicate that the fixed bridge indicated is
to replace posterior teeth #'s 2 and 4. This is not a covered expense.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the pontics and retainer crowns have not been met. Therefore, we decided that
the Plan does not have to pre-approve pontics (D6240) for tooth #'s 2 and 4 and retainer crowns (D6750) for
tooth #'s 3 and 5.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high-strength lightweight manual wheelchair.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of a requirement for a custom seat not available on a standard, lightweight, or hemi-wheelchair.
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 wheelchair. Our reviewer says that the requested wheelchair is not considered medically reasonable and necessary in this case. Our physician reviewer found the treating medical provider documentation indicates that you have a mobility limitation but it is not clear that this deficit significantly impairs the ability to complete MRADLs in the home, or why the deficit cannot be resolved by a cane or walker. It is not clear that the requested wheelchair will significantly improve your ability to participate in MRADLs in the home, per the treating provider records. The documentation is not clear that a caregiver could propel the requested wheelchair. It is not clear if you engage in activities in the home that cannot be performed in a standard or lightweight wheelchair. The documentation does not reveal that you require a seat width/height/depth that cannot be accomodated in a standard chair. 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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a high-strength lightweight manual wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Contour Next test strips.
You asked the Plan to pre-approve Contour Next test strips. You say that the items 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 MA plans may specify brands and manufacturers
as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those
preferred brands and manufacturers, as long as specific criteria is met.
We looked at the file and Medicare rules. Specifically, medical records were not received from the prescribing
physician to support the need for a non-preferred brand test strip. Based on this information, we decided that
Medicare rules for coverage of Contour Next test strips have not been met. Therefore, we decided that the Plan
does not have to pre-approve Contour Next test strips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. 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. 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 medication is not medically necessary. Our physician reviewer found there is no off-label use supported by major drug compendia or the medical literature for 1st line therapy. This enrollee has not received prior therapy for her endometrial cancer 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 Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultralight wheelchair for the enrollee.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says this request is considered duplicative.
The Plan follows Medicare rules. Medicare rules say that a wheelchair 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 the wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the clinical notes did not show that the enrollee is a full time wheelchair user. The enrollee must be a full time wheelchair use to be indicated for an ultralight wheelchair. Furthermore, the documentation reveals that you have a mobility limitation, but it is not clear that it significantly impairs the ability to complete MRADLs or an objective detailed neuromuscular or gait evaluation indicating the mobility deficit cannot be resolved by a walker, or that your home is appropriate for the wheelchair. The documentation is not clear that this wheelchair will significantly improve your ability to participate in MRADLs, or that you or your caregiver could propel the wheelchair. You do not require this wheelchair, especially with a transport wheelchair being authorized. 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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve an ultralight wheelchair for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2751) for tooth #8.
You asked the Plan to pre-approve the crown. The Plan denied your request. The Plan says it is not medically
necessary to replace the cap on your tooth.
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. The Plan covers the crown
when the services are medically necessary and reasonable.
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 crown. Our reviewer says that the
crown is not medically reasonable and necessary. Our physician reviewer found the provided x-ray shows an
existing post and crown on tooth #8, with no visible defect seen. The tooth had prior endodontic therapy, and
appears to have been properly restored with a post and crown. Our reviewer found that there is no apparent
defect with the current post and crown, and as such there is no justification to replace the existing prosthesis.
Once it has been determined a crown is necessary for a situation, only a defect that makes it non-serviceable
would justify its replacement. Our physician reviewer also found that given the supplied information and lack
of any supporting statement from the dental provider, there is no medical necessity for a replacement post and
crown.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have
to pre-approve a crown (D2751) for tooth #8.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Zilretta Suser Vial.
You asked the Plan to pre-approve the Zilretta Suser Vial. You say that the enrollee is not a surgical candidate,
and patients have great success with Zilretta. The Plan denied your request. The Plan says the information
provided does not indicate the member has had an adequate trial of Triamcinolone injection with an inadequate
response or intolerance.
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 the Zilretta Suser Vial. Our reviewer
says that the Zilretta Suser Vial is not medically reasonable and necessary for the enrollee. Our physician
reviewer found the enrollee has not trialed both Triamcinolone and Dexamethasone injections. Step therapy, as
outlined by the Plan, requires these be trialed first. Our reviewer found that the documentation does not outline
contraindications or reasons these medications were not considered. Our physician reviewer also found that
without the support of the documentation, Zilretta is not approved as step criteria is not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the Zilretta Suser Vial have not been met. Therefore, we decided that the Plan
does not have to pre-approve a Zilretta Suser Vial.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on 
October 12, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic mammogram. You say that you disagree with the 
charges because you were told that this would be considered a mammogram screening. The Plan denied your 
request. The Plan says the claims were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for each basic imaging service. 
 
The medical records show that you received a diagnostic mammogram on October 12, 2020. Therefore, you are 
responsible to pay the $10 copayment.   
 
You have been asked to pay a $10 copayment for a diagnostic mammogram. A diagnostic mammogram 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 a diagnostic mammogram provided on October 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on September 8, 2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges. 
The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the 
correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for each specialist visit.  
 
You have been asked to pay a $45 copayment for a specialist visit. A specialist visit falls within the outpatient 
hospital services 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 a specialist visit 
provided on September 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray provided on September 18, 2020. 
 
You asked the Plan to pay for the first intraoral periapical x-ray. You say that the provider incorrectly billed 
you for x-rays that you did not receive. The Plan denied your request. The Plan says this is not 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. Bitewing x-rays are the only covered x-rays under your plan. 
Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray provided on 
September 18, 2020.