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

We decided that the Plan does not have to pay for the physician services provided on November 19, 2020, by
an OON provider.
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network
care.
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 the physician services provided on November 19,
2020, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an abutment supported crown (D6058) provided on January 27, 2021.

You asked the Plan to pay for the abutment supported crown. You say that you should have money left in your dental allowance and this service should be covered as your dentist found it necessary. You also sent a separate statement to us indicating that this item was billed incorrectly. The Plan denied your request. The Plan says this service is not covered by Medicare or by the Plan's supplemental 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 pay for an abutment supported crown (D6058) provided on January 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy (D3330).
You asked the Plan to pre-approve endodontic therapy. You say that this is medically necessary. The Plan denied your request. The Plan says this is 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 endodontic therapy (D3330).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Metanx.
You asked the Plan to pre-approve Metanx. You say that the enrollee is intolerant of other medications. 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 Metanx.
Benefits for Metanx 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 void payment for the partial upper denture (D5213) and the partial
lower denture (D5214) provided on November 19, 2020.

You asked the Plan to void payment for the dental services. You say that your dentist never discussed the
partial with you. You say that your dentist just said that your insurance would cover it. You say that you were
shown the partials when they were 80% completed. You say that you called the office to tell them to stop the
work on the partials because you were not happy with them. You also say that you saw a charge for something
that you do not have and would not want in your mouth permanently. The Plan denied your request. The Plan
says partial dentures are listed as a covered service. The Plan says that the provider's office has confirmed
immediate dentures have been made. The Plan says that since the services have been performed, the provider is
eligible for payment.

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 void payment for
the partial upper denture (D5213) and the partial lower denture (D5214) provided on November 19, 2020.

Your complaint about not being satisfied with the partials is not a valid appeal for medical coverage. This part
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a
decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on September 11, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 the physician services provided on September 11, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion interspinous spacer for the enrollee.
You asked the Plan to pre-approve these services. You say that the enrollee is in pain and this is medically necessary. The Plan denied your request. The Plan says that this service is considered experimental and 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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The superion spacer remains experimental. More research is needed to show safety and efficacy of the device. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 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-approve a Superion interspinous spacer for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Neulasta (pegfilgrastim) injections.
You asked the Plan to pre-approve the Neulasta injections. You say that it is felt that this particular drug is medically necessary. The Plan denied your request. The Plan says there is no evidence that the preferred drugs would be less effective.
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 Neulasta injections. Our reviewer says that the documentation does not support the medical necessity of the requested drug. Our physician reviewer found the enrollee has colon cancer. The records provided do not indicate a sufficient rationale why the plan's preferred alternatives would not be appropriate for the enrollee. The requested drug would be a new start. The elements of the step therapy 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 the Neulasta injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Neulasta (pegfilgrastim) injections.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fentanyl patch.
You asked the Plan to pre-approve Fentanyl patch. You say that this drug is medically necessary. The Plan
denied your request. The Plan says this drug is not covered under the Plan's medical 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 Fentanyl patch.
Benefits for Fentanyl patch 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgent care services (S9088, 69200) provided on February 8, 2021.
You asked the Plan to waive the copayment for urgent care services. You say that you do not think you should be responsible for the copayment. 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 $65 copayment for urgently needed services. You have been asked to pay a $65 copayment for urgent care services. The services at issue fall within the urgently needed 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 urgent care services (S9088, 69200) provided on February 8, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for family psychotherapy provided on October 9, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the family psychotherapy. 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the family psychotherapy provided on October 9, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the continuous positive airway pressure (CPAP) device purchased on December 15, 2020.
You asked the Plan to reimburse you for the CPAP device. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for the continuous positive airway pressure (CPAP) device purchased on December 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a "hurry cane."
You asked the Plan to pre-approve the cane. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered a convenience item.
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 cane. Our reviewer says that the requested cane is not considered medically reasonable and necessary in this case. Our physician reviewer found you have reported falls. The medical record indicates that you ambulate with a regular cane. The medical record does not indicate the medical necessity and reasonableness of the requested service. 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 cane have not been met. Therefore, we decided that the Plan does not have to pre-approve a "hurry cane."
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an advanced foot feature (L5981, L5986) for a prosthetic leg.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the request for a K3 foot does not meet Medicare criteria as reasonable and necessary.
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found evidence of the use of a cane with ambulation in the medical progress notes do not support that you are a K3 ambulator.
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-approve an advanced foot feature (L5981, L5986) for a prosthetic leg.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on October
31, 2020.

You asked the Plan to waive the copayment for ambulance services. You say that you would like the
copayment waived because you had a bad reaction to a Cortisone shot and became unconscious. 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 $350
copayment for ambulance services.

You have been asked to pay a $350 copayment for ambulance services. Ambulance services fall within the
ambulance 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 ambulance services
provided on October 31, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening mammogram provided on August 29, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the screening mammogram. You say that you are resubmitting the claim with documentation supporting payment for the frequency of this service. 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 screening mammogram provided on August 29, 2019 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services of home health/hospice aide (G0156) and direct
skilled nursing services of a RN (G0299).
You asked the Plan to pre-approve the services of home health/hospice aide and direct skilled nursing services
of a RN. The Plan denied your request. The Plan says you do not require the skill level of a home health aide.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 of home health/hospice
aide and direct skilled nursing services of a RN. Our reviewer says that the requested home health services are
not medically necessary. Our physician reviewer found the documentation does not support that you require
additional skilled nursing services home health aide services to provide treatment that is medically necessary.
Our reviewer found that you do not require additional skilled nursing services to effectively provide treatment,
care, and/or services in order to improve your condition, perform a maintenance program to maintain your
condition and/or prevent deterioration. Our physician reviewer also found that you have been medically stable
without any recent exacerbations of chronic medical problems or hospitalizations.
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 of home health/hospice aide and direct skilled nursing services of a
RN have not been met. Therefore, we decided that the Plan does not have to pre-approve services of home
health/hospice aide (G0156) and direct skilled nursing services of a RN (G0299).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the early episode provided on November 12, 2020 by an OON provider.
You asked the Plan to pay for the early episode. The Plan denied your request. The Plan says the service was rendered by a non-participating provider. The Plan also says that prior authorization was not 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the early episode provided on November 12, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the therapeutic continuous glucose monitor system provided on
December 31, 2020.
You asked the Plan to pay for the therapeutic continuous glucose monitor system. You say that the Plan should
pay this claim. The Plan denied your request. The Plan says that there is no Delivery Ticket or Proof of
Delivery submitted.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record now contains proof of delivery for the supplies provided in this case. The record shows that the Plan
made several attempts to obtain the necessary documentation without success. However, the provider submitted
Proof of Delivery documentation to Maximus. Therefore, we decided that the Plan has to pay for the
therapeutic continuous glucose monitor system provided on December 31, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction of intraosseous basivertebral nerve (Intracept procedure).
You asked the Plan to pre-approve Intracept. You say that this procedure is not investigational and is medically necessary for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee would most likely not benefit from Intracept.
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 Intracept. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is considered experimental/investigational. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction of intraosseous basivertebral nerve (Intracept procedure).