Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for 3 additional surgical extraction (D7210) and the alveoloplasty in conjunction with an extraction (D7311) provided on October 12, 2020.

You asked the Plan to reimburse you for the dental services. You say that the oral surgeon is out of network. You say that the book says a percentage should be paid on the 2 teeth that were denied. You also say that you would like to know if anything will be paid on the 2 bridge you will need. The Plan denied your request. The Plan says 2 extractions per calendar year are covered with a 55% coinsurance when you receive them in network. The Plan says that the frequency limit for this service has been exceeded. The Plan says that alveoloplasty in conjunction with an extraction 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 frequency limit of 2 extractions per calendar year has been exceeded. The record shows that the Plan paid for 2 extractions that you received on this date of service with the 45% coinsurance. Additionally, the alveoloplasty in conjunction with an extraction is not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for 3 additional surgical extraction (D7210) and the alveoloplasty in conjunction with an extraction (D7311) provided on October 12, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric services provided on April 24, 2019.

You asked the Plan to pay for the psychiatric services. You say that you did not receive proper notice of the enrollee's benefit determination. The Plan denied your request. The Plan says the claim was untimely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the psychiatric services was not filed until August 27, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the psychiatric services provided on April 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (31623).

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot be verified.

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 31623 is "Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with brushing or protected brushings."

We asked our coding 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 pay for the services. Our reviewer says that the use of code 31623 is not supported by the records provided. Our coding reviewer found that the documentation does not support fluoroscopic guidance as well as brushings or protected brushings. Therefore, CPT code 31623 cannot be verified as performed.

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 services have not been met. Therefore, we decided that the Plan does not have to pay for the services (31623).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve reconstruction of the jaw (21248), two alveoloplasties (41874 x2), two lower jaw bone grafts (21215 x2), impression and custom preparation (21085), and interim obturator prosthesis (21079).

You asked the Plan to pre-approve the reconstruction of the jaw, alveoloplasties, bone grafts, impression and custom preparation, and interim obturator prosthesis. You say that this oral surgery will benefit the enrollee. The Plan denied your request. The Plan says the enrollee does not meet the conditions for payment of these services, as the enrollee's Evidence of Coverage does not provide a benefit for the services requested.

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 reconstruction of the jaw, alveoloplasties, bone grafts, impression and custom preparation, and interim obturator prosthesis 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 reconstruction of the jaw, alveoloplasties, bone grafts, impression and custom preparation, and interim obturator prosthesis. Our reviewer says that these services are not considered a treatment for a medical condition. Our physician reviewer found the services indicated are for the replacement of teeth and supporting structures. Our reviewer also found that under the terms of the Plan these services are not covered expenses.

We looked at this physician's review, the file, and Medicare rules. These services are considered dental, and are not among the dental services covered by the Plan. Based on this information, we decided that the Plan's rules for coverage of the reconstruction of the jaw, alveoloplasties, bone grafts, impression and custom preparation, and interim obturator prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve reconstruction of the jaw (21248), two alveoloplasties (41874 x2), two lower jaw bone grafts (21215 x2), impression and custom preparation (21085), and interim obturator prosthesis (21079).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laparoscopy provided on October 28,
2020.

You asked the Plan to waive the copayment for the laparoscopy. You say that you had a colonoscopy with no
copayment and its almost the same procedure so there should not be a copayment. The Plan denied your
request. The Plan says you were charged this copayment 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 Outpatient Surgery.

You have been asked to pay a $250 copayment for the laparoscopy. The laparoscopy falls within the Outpatient
Surgery 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 laparoscopy provided
on October 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the sterilization procedure, vasectomy (55250).

You asked the Plan to pay for the vasectomy. You say that you was given a reference from your PCP to get services from this provider and wasn't aware you would have to pay this yourself. You did not know it was a cost for in-network services. The Plan denied your request. The Plan says per Medicare guidelines, this service is not covered because the records show you underwent this procedure for the purpose of sterilization.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the vasectomy have not been met. Therefore, we decided that the Plan does not have to pay for the sterilization procedure, vasectomy (55250).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the BLS non-emergency ambulance (A0428) ground mileage
(A0425) provided by an out-of-network (OON) provider.

You asked the Plan to pay for the ambulance services. You say that per the Plan's guidelines, claims with HE
modifiers do not require prior authorization. Please resubmit for reconsideration and payment. The Plan denied
your request. The Plan says enrollee's must receive their medical services from an in-network provider with the
exception being urgent or emergent services. Non-emergent services with non-contracted providers require
prior authorization before services being rendered.

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 health plan contract, on page 58, also says that prior
authorization is required for fixed wing transports and all other ambulance transportation with the exception of
emergency ambulance transport and facility to facility transfers.

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 BLS non-emergency ambulance (A0428)
ground mileage (A0425) provided by an out-of-network (OON) provider.
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 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 IRF admission is covered only when it is medically reasonable and necessary as described above. 

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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that you 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 pay for the lower partial denture.

You asked the Plan to pay for the lower partial denture. You say that the partial denture does not fit you well. You say that you have not been able to use it. You say that you have gone in several times to have it fixed. You say that you are being told that it needs to be remade. You also say that you cannot afford any more charges. The Plan denied your request. The Plan says lower partial denture 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 lower partial denture is not among those covered under this benefit. The Evidence of Coverage clearly states that any services not listed are not covered. Therefore, we decided that the Plan does not have to pay for the lower partial denture.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Prothrombin time test (85610).

You asked the Plan to waive the copayment for the Prothrombin time tests. You say that you should not be
charged a copayment for the office visit portion of your bill. The Plan denied your request. The Plan says the
copayment for the laboratory services 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 $10
copayment per visit for laboratory tests, non-radiological diagnostic tests, flat film x-rays, and ultrasounds.

You have been asked to pay a total of $12.87 for the three Prothrombin time tests. This service 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 the Prothrombin time test (85610).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ALS routine disposable supplies (A0398) provided February
4, 2020.

You asked the Plan to pay for the disposable supplies. You say that you request that this claim be reviewed
based on medical necessity and request that this claim be reprocessed. The Plan denied your request. The Plan
says payment for these items is included in the payment for the ambulance transport.

The Plan must follow Medicare rules. Medicare rules say that oxygen and other items and services provided as
part of the transport are included in the fee schedule base payment rate and are not separately payable.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the disposable supplies have not been met. Therefore, we decided that the Plan does not have to
pay for ALS routine disposable supplies (A0398) provided February 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and does not require transfer to LTACH.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee is receiving appropriate care at the present acute care hospital. There are no services at the LTACH that cannot be obtained at the hospital setting being offered by the health plan. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BROVANA.

You asked the Plan to pre-approve BROVANA. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.

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 BROVANA. Our reviewer says that the
documentation does not support that the requested drug is medically reasonable or necessary. Our physician
reviewer found the enrollee has chronic obstructive pulmonary disease. The documentation indicates that the
enrollee was previously on Symbicort but this was stopped due to voice change and thrush following vocal
cord surgery. The documentation does not support that the enrollee has tried and failed PERFOROMIST. The
documentation does not support that the enrollee has a contraindication to or intolerance to the required step
therapy drug. Therefore, the enrollee does not meet criteria for the requested drug.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of BROVANA have not been met. Therefore, we decided that the Plan does not
have to pre-approve BROVANA.
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 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 IRF admission is covered only when it is medically reasonable and necessary as described above.

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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on August 18, 2020.

You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent
or emergent, nor were they approved in advance.

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
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for nurse practitioner services provided on August 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on July 9, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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/services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on July 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Herceptin and Granisetron.
You asked the Plan to pre-approve the requested drug. You say that the enrollee has not responded to other medications. The Plan denied your request. The Plan says the drug regimen is not being prescribed for a medically-accepted indication.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 requested drug. Our physician reviewer found that the requested use of Herceptin and Granisetron is not FDA-approved for the enrollee's diagnosis. The use is not supported by one of the major drug compendia, or by clinical research that appears in a CMS-approved medical journal. The compendia supports the use for HER2+ serous endometrial cancer, but this enrollee is mixed histology. The use is not listed as not indicated, not supported or not recommended in any of the compendia. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee 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 requested drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Herceptin and Granisetron.