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

We decided that the Plan does not have to pay for the periodic oral evaluation provided on November 4, 2019.
You asked the Plan to pay for the periodic oral evaluation. You say that this was your first preventive visit. You also say that your previous visit on August 8, 2019 was problem focused and should not go against your preventive services. The Plan denied your request. The Plan says this service exceeds the frequency limitation allowed in your benefit plan.
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, oral exams are limited to up to 1 visit every 6 months. The record shows that you received a problem focused limited oral evaluation on August 9, 2019 and your oral exams benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation provided on November 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on November 19, 2019.
You asked the Plan to pay for the dental services. You say that you called the plan to renew your gold plus policy for 2019. You say you were advised that it would roll over. You say that it did not. You say that you used to have 2 cleanings covered per year and now only have one. You also say that you were not aware that the policy changed. The Plan denied your request. The Plan says the 2018 and 2019 Evidence of Coverage both state that 1 cleaning per year are covered. The Plan also says the frequency limit of 1 cleaning per year has been exceeded.
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 and oral exams and cleanings are covered services, the frequency limit of 1 per year has been exceeded. The record shows that the Plan previously paid for these services that you received on January 4, 2019. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on November 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Palonosetron hydrochloride.
You asked the Plan to pre-approve Palonosetron hydrochloride. You say that the enrollee needs this medication due to his chemotherapy. The Plan denied your request. The Plan says this is not medically necessary.
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 Palonosetron hydrochloride. Our reviewer says that Palonosetron hydrochloride is not medically necessary at this time. Our physician reviewer found the drug is indicated for use in moderately and highly emetogenic chemotherapy. The chemotherapy being given to the enrollee has low emetic potential. The documentation does not support that the drug is medically reasonable and necessary nor that it is safe and effective for the 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 Palonosetron hydrochloride have not been met. Therefore, we decided that the Plan does not have to pre-approve Palonosetron hydrochloride.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have the pre-approve Tecentriq to be used in conjunction with Mvasi.
You asked the Plan the pre-approve the Tecentriq. You say that the use of this drug is medically necessary for the treatment of the member's condition. The Plan denied your request. The Plan says this drug is denied as off-label for being used in conjunction with Mvasi for treatment of hepatocellular cancer.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 the pre-approve the Tecentriq. Our reviewer says that this drug is not FDA approved for the requested use. Our physician reviewer found this drug is not supported by any of the CMS compendia for the requested use. 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 Tecentriq have not been met. Therefore, we decided that the Plan does not have the pre-approve Tecentriq to be used in conjunction with Mvasi.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient surgery provided on September 3, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an outpatient surgery. You say that these services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained for these services.
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 has network providers available who can provide 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 an outpatient surgery provided on September 3, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair for the enrollee.
You asked the Plan to pre-approve a shower chair. You say that the enrollee would benefit from a shower chair for her safety. The Plan denied your request. The Plan says the shower chair is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on August 1, 2019.
You asked the Plan to pay for the services. You say that the services were necessary. The Plan denied your request. The Plan says there is no network deficiency for these services.
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 has network providers available who can provide 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 the enrollee by an out-of-network provider on August 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One (J7325).
You asked the Plan to pre-approve the Synvisc-One. You say that Synvisc-One is medically necessary for treatment of the member's condition. The Plan denied your request. The Plan says step therapy exception criteria have not been met.
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 Synvisc-One. Our reviewer says that the member has not tried and failed a trial of Monovisc and Orthovisc. Our physician reviewer found the documentation does not indicate that the Plan's required drugs would likely be less effective or have adverse effects. 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 Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One (J7325).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed.
You asked the Plan to pre-approve a heavy duty extra wide hospital bed. You say that the enrollee cannot climb
stairs in the home and needs a hospital bed on the first floor. The Plan denied your request. The Plan says
criteria for a hospital bed have not been met.
The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary
when the patient:
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or
2. Requires attachments which can only be attached to a hospital bed; AND
3. Requires the head of the bed to be elevated.
We looked at the file and Medicare rules. The records do not support the criteria. Based on this information, we
decided that Medicare rules for coverage of a heavy duty extra wide hospital bed have not been met. Therefore,
we decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that the member's ongoing specialized therapy needs for ambulation can be met in his current location.
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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral foot orthotic inserts (L3000).
You asked the Plan to pay for the foot orthotics inserts. You say that the claim should be paid. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for bilateral foot orthotic inserts (L3000).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Alfuzosin for the enrollee.
You asked the Plan to pre-approve this drug. You say that this has worked for the enrollee previously. The Plan denied your request. The Plan says that this medication is not covered under Part B.
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 Alfuzosin for the enrollee.
Benefits for this drug 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that you no longer require skilled services and the continuation of SNF is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on September 26, 2019.
You asked the Plan to waive the copayment for the ambulance ride. You say that you did not request the ambulance service so you should not be responsible for the copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for Medicare-covered ground ambulance benefits. You have been asked to pay a $100 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance services" benefit category. The record shows you were transported by ambulance.
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 ride provided on September 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lyrica for the enrollee.
You asked the Plan to pre-approve Lyrica. You say that the enrollee needs this for the treatment of multiple sclerosis. The Plan denied your request. The Plan says that this is not Medicare covered under the Part A or B 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 Lyrica for the enrollee.
Benefits for Lyrica 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 copayments for the urgent care visits provided on July 11, 2019 and July 23, 2019.
You asked the Plan to waive the copayments for the urgent care visits. You say that you did not know you had a $50 copayment for the urgent care visit. You say you live on Social Security and need help. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for each urgently needed visit in a non-contracted Urgent Care Center or walk-in clinic in the United States. You have been asked to pay a $50 copayment for each of the urgent care visits. The urgent care visits 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 copayments for the urgent care visits provided on July 11, 2019 and July 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the prophylaxis (D1110), the bitewing x-rays (D0274), the topical application of fluoride varnish (D1206), and the resin based composite (D2330) provided from October 14, 2019 to October 24, 2019.
You asked the Plan to pay for the dental services. You say that you were informed by 2 different people that the provider was in network. You say that since you were misinformed, the services should be covered. You also say that you are on a limited income and cannot afford extra charges by going out of network providers. The Plan denied your request. The Plan says services must be received from in network providers in order to be covered. The Plan also says that the provider in this case is not a network provider.
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, dental services must be received in network in order to be covered. The record shows there is no call on record for the date October 7, 2019. The Plan says that there was a call on record for November 7, 2019 where the plan representative confirmed that the provider is not in your network. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the prophylaxis (D1110), the bitewing x-rays (D0274), the topical application of fluoride varnish (D1206), and the resin based composite (D2330) provided from October 14, 2019 to October 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on August 16, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that you were told to submit the bill to see if you might be able to have more help with paying it. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office.
You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" 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 specialist office visit provided on August 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy, molar tooth (D3330) and core
buildup (D2950).
You asked the Plan to pre-approve endodontic therapy and core buildup. 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.
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, molar tooth (D3330) and core buildup (D2950).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve ablation (64640).
You asked the Plan to pre-approve genicular nerve ablation. You say that you need this to relieve your chronic
pain. The Plan denied your request. The Plan says research does not show that this procedure is as good or
better than other treatments.
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 genicular nerve ablation. Our reviewer
says that the requested services is not considered medically reasonable and necessary in this case. Our
physician reviewer found this is an experimental/ investigational procedure that is the subject of on-going
clinical trials. Therefore, the request is considered not medically reasonable or 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 genicular nerve ablation have not been met. Therefore, we decided that the Plan
does not have to pre-approve genicular nerve ablation (64640).