Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit.

You asked the Plan to pre-approve Procrit. You say that the requested Procrit is medically necessary. The Plan
denied your request. The Plan says the enrollee must try and fail Retacrit first.

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 Procrit. Our reviewer says that the
Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee has a diagnosis of
Chronic kidney disease, stage 3b, with anemia. The case file does not contain documentation of trial and failure
of Retacrit. The documentation does not support that Retacrit would likely be less effective, and/or would
likely have adverse effects for the enrollee in this case.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to
pre-approve Procrit.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve destruction of lower or sacral spinal facet joint nerves using imaging guidance.

You asked the Plan to pre-approve destruction of lower or sacral spinal facet joint nerves using imaging guidance. 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 follows Medicare rules. Medicare rules say that Thermal Medial Branch Radiofrequency Neurotomy is covered 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 destruction of lower or sacral spinal facet joint nerves using imaging guidance. Our reviewer says that the services are medically necessary.

Our physician reviewer found the pain complaints and signs are consistent with the prior Right lumbar facet originated pain. There is no new issue presented. The request is medically reasonable and 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 destruction of lower or sacral spinal facet joint nerves using imaging guidance have been met. Therefore, we decided that the Plan has to pre-approve destruction of lower or sacral spinal facet joint nerves using imaging guidance.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Temazepam Cap 15mg.

You asked the Plan to pre-approve Temazepam. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.

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 Temazepam Cap 15mg.

Benefits for Temazepam 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 pay for the two additional radiographic images (D0230) provided December 10, 2020.

You asked the Plan to pay for the two additional periapical x-rays. You say that your dental provider was switched when you were to your appointment. The Plan denied your request. The Plan says while claims from this date of service were reprocessed, only one periapical x-ray is covered under your benefits and therefore the additional periapical x-rays 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. The Plan covers one periapical x-ray per calendar year. 

We looked at the file and Medicare rules. The Plan has provided documentation that they have already covered one periapical x-ray in the 2020 calendar year. Based on this information, we decided that the Plan's rules for coverage of the two periapical x-rays have not been met. Therefore, we decided that the Plan does not have to pay for the two additional radiographic images (D0230) provided December 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services provided to the enrollee on November 19, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the provider is inconsistent with the modifier used.

The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a Physician, PA, NP, or CNS. 

In this case, the record does not show that the provider of the surgical assistant service is a Physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services provided to the enrollee on November 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on January 5, 2021.

You asked the Plan to pay for the dental service. You say that this teeth cleaning should be covered under your policy. The Plan denied your request. The Plan says periodontal maintenance 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 pay for the periodontal maintenance (D4910) provided on January 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), periapical first radiographic images (D0220), and resin-based composite (D2335) provided December 9, 2020.

You asked the Plan to pay for the limited problem focused dental exam, periapical x-rays and resin-based composites. You say that the services should be covered. The Plan denied your request. The Plan says these services are not covered under your dental benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the limited oral evaluation and periapical x-ray are not among those covered under this benefit. Resin-based composites are covered by the Plan twice per calendar year, however, since the service was provided by an OON provider, you are responsible for 100% of the cost. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), periapical first radiographic images (D0220), and resin-based composite (D2335) provided December 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electroencephalogram (95720) provided on March 28, 2020.

You asked the Plan to pay for the electroencephalogram. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.

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 95720 is electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, each increment of greater than 12 hours, up to 26 hours of EEG recording, interpretation and report after each 24-hour period; with video (VEEG).

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the electroencephalogram. Our reviewer says that CPT code 95720 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include documentation to meet definition criteria of CPT cod 95720, therefore this procedure cannot be verified.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the electroencephalogram have not been met. Therefore, we decided that the Plan does not have to pay for the electroencephalogram (95720) provided on March 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from September 11, 2020, through September 14, 2020.

You asked the Plan to waive the copayment for the inpatient stay. You say that you were hospitalized but the provider is in your Plan. You say that the bill should be considered for payment. The Plan denied your request. The Plan says the claim was reprocessed to apply the in-network copayment.

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 $210 copayment per day for days 1-7 for each in-network, Medicare covered hospital stay.

You have been asked to pay a $420 copayment for the inpatient stay. ($210/day x 2 days = $420). The inpatient stay 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 copayment for the inpatient stay provided from September 11, 2020, through September 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required, custom fabricated abutment, abutment supported porcelain fused to metal crown, or pay the in-network rate for the crown provided from July 6, 2020, to October 7, 2020 by an OON provider.

You asked the Plan to pay for the core buildup, including any pins when required, custom fabricated abutment, abutment supported porcelain fused to metal crown, and crown. You say that you would like to appeal these services. The Plan denied your request. The Plan says there is no coverage for the core buildup, including any pins when required, custom fabricated abutment, and abutment supported porcelain fused to metal crown under your plan. The Plan also says that you are responsible for the difference between the in-network fee schedule (INFS) and dentists' charged fees for the crown when visiting an out-of-network dentist.

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 core buildup, including any pins when required, custom fabricated abutment, and abutment supported porcelain fused to metal crown are not among those covered under this benefit. The contract also states that you must pay a 75% coinsurance plus the difference between the provider's billed amount and the allowed amount for the crown because it was received OON.

Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when required, custom fabricated abutment, abutment supported porcelain fused to metal crown, or pay the in-network rate for the crown provided from July 6, 2020, to October 7, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic radiographic images (D0330) provided December 28, 2020.

You asked the Plan to pay for the panoramic x-rays. You say that you are unable to locate information explaining why this service isn't covered. The Plan denied your request. The Plan says the EOC does not list this 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 pay for the panoramic radiographic images (D0330) provided December 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Arthrocentesis provided on September 29, 2020.

You asked the Plan to waive the copayment for the Arthrocentesis. You say that you paid in advance for the medicine injected. You say that you are being billed for charges you already paid that the Plan should have covered. The Plan denied your request. The Plan says the copayment applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for surgery services at an in-network outpatient hospital.

You have been asked to pay a $250 copayment for the Arthrocentesis. The Arthrocentesis falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show this copayment applies to the surgical service for the injection. 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 Arthrocentesis provided on September 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for over-the-counter benefit reimbursement for items purchased from a non-participating store from May 1, 2020, to July 1, 2020.

You asked the Plan to pay for over-the-counter items. You say that you were not told you would not be reimbursed for items purchased at this store. The Plan denied your request. The Plan says the denial of payment for these items is correct, because over-the-counter benefits are not covered when purchased from a non-participating store.

The Plan must follow Medicare rules. Medicare rules say that over-the-counter items are not generally covered. The Plan has a supplemental over-the-counter benefit that goes beyond Medicare's coverage. For that reason, the Plan's rules apply.

We looked at the file, Medicare rules, and the Plan's rules. The Plan's over-the-counter benefit is not covered when items are purchased from a non-participating store. Based on this information, we decided that the Plan's rules for coverage of over-the-counter items have not been met. Therefore, we decided that the Plan does not have to pay for over-the-counter benefit reimbursement for items purchased from a non-participating store from May 1, 2020, to July 1, 2020.
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 you would like reconsideration because the member meets inpatient criteria. The Plan denied your request. The Plan says this IRF care is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There are no complex nursing or rehabilitation needs.

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 pay for the problem focused limited oral evaluation provided on December 21, 2020.

You asked the Plan to pay for the problem focused limited oral evaluation. You say that you believe this service should be paid in full. The Plan denied your request. The Plan says this service is not covered. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.

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 problem focused limited oral evaluation provided on December 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a Laryngoscopy (31536) provided September 21, 2020.

You asked the Plan to pay for the Laryngoscopy. You say that the service was medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.

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 31536 is Laryngoscopy, direct, operative, with biopsy; with operating microscope or telescope.

We find that CPT code 31536 is not supported in the medical record. Specifically, medical records do not include documentation of a Laryngoscopy, direct, operative, with biopsy; with operating microscope or telescope being performed. Based on this information, we decided that Medicare rules for coverage of the Laryngoscopy have not been met. Therefore, we decided that the Plan does not have to pay for a Laryngoscopy (31536) provided September 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a second annual exam received on November 16, 2020.
You asked the Plan to pay for the second exam. You say that the first visit should not count as the preventive exam, as you went regarding menopause issues. The Plan denied your request. The Plan says the benefit has been exhausted.
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 are entitled to one wellness exam each calendar year. You have been asked to pay for the second exam you received in calendar year 2020. You already received a preventive wellness exam in 2020 on September 16th. This means that you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay for a second annual exam received on November 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation service (A0427, A0425) provided on July 21, 2020.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 $300 copayment per one-way trip via ground or air ambulance. 

You have been asked to pay a $300 copayment for the one-way ground ambulance transport provided. 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 ambulance transportation service (A0427, A0425) provided on July 21, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy provided on November 2, 2020.

You asked the Plan to waive the copayment for the endoscopy. You say that this is a preventive outpatient procedure not outpatient surgery. The Plan denied your request. The Plan says the copayment applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $395 copayment for each Medicare-covered outpatient surgery or procedure at an in-network outpatient hospital facility or ambulatory surgical center.

You have been asked to pay a $395 copayment for the endoscopy. The endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The endoscopy is considered a surgical service. 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 endoscopy provided on November 2, 2020.