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

We decided that the Plan does not have to pay forthe dental services provided on May 29, 2020.You asked the Plan to pay forthe dental services. 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.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, wedecided that the Plan does not have to pay forthe dental services provided on May 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shares forthe home infusion therapy services provided from September 18, 2020, to September 24, 2020.You asked the Plan to waive the cost shares forthe services provided. You say that the prescription should be covered under Part D.The Plan denied your request. The Plan says the coinsurance 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 20% of the plan-allowed amount for Medicare Part B prescription drugs. You have been asked to pay 20% of the plan-allowed amount for the services provided. The services fallwithin the Medicare Part B prescription drugs benefit category.Covered services include drugs you take using durable medical equipment.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 nothave to waive the cost shares forthe home infusion therapy services provided from September 18, 2020, to September 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, two first intraoral periapical x-rays, and extraction provided by OON provider.

You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and extraction. You say that you felt this was an emergency service.The Plan denied your request. The Plan says these services were rendered by a non-contracted 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, the requested items or services are not covered when they are received OON.Therefore, we decided that the Plan does not have to pay fo rthe problem focused limited oral evaluation, two first intraoral periapical x-rays, and extraction provided by OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha Soln Pref syringe 140mg/ml.

You asked the Plan to pre-approve the drug. You say that this is medically necessary.The Plan denied your request. The Plan says you do not have Medicare Part D benefits with the 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 Repatha Soln Pref syringe 140mg/m
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Vertiflex Superion spacer.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has moderate spinal stenosis at three lumbar levels. There is no discussion ofspinal instability on flexion/extension films. The Superion spacer is not the standard of care and is not medically necessary for the enrollee's condition.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-approvea Vertiflex Superion spacer.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveEuflexxa.You asked the Plan to pre-approveEuflexxa. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the requested drug 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 Euflexxa. Our reviewer says that the documentation supports that the requested drug is medically reasonable and necessary. Our physician reviewer found the enrollee has bilateral osteoarthritis of her knees. The enrollee takes Ibuprofen for pain. The enrollee has had intra-articular steroid injections and a trial of physical therapy. The request meets all of the criteria of the LCD. Therefore, the enrollee meets 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 Euflexxa have not been met.Therefore, we decided that the Plan has to pre-approveEuflexxa.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again ifwe 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on January 10, 2019, by an out-of-network (OON) provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.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 forthe medical services provided on January 10, 2019, by an out-of-network (OON) provider.
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 July 29, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that only your tongue was looked at during this visit, not your teeth. You also say that you feel this is a medical claim, and not dental. The Plan denied your request. The Plan says this service 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 pay for the problem focused limited oral evaluation provided on July 29, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProlia.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plandenied your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has osteoporosis and has not tried the Plan's required drug, zoledronic acid. The records do not support that the required drug would be contraindicated or less effective; therefore, the requested Prolia is not reasonable or medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe laboratory work provided on July 24, 2020.You asked the Plan to waive the copayment forthe laboratory work. You say that you have had this testing done in the past and have not had a 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 $20 copayment per visit for laboratory tests, non-radiological diagnostic tests, flat film x-rays, and ultrasounds. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $20 copayment for laboratory work.You have been asked to pay a $12.28 copayment for the laboratory work. The laboratory work 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 thePlan. 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 forthe laboratory work provided on July 24, 2020.Our decision is only aboutthe July 24, 2020 services. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe enteral formula rendered on March 2, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating physician before dispensing any DMEPOS item to a beneficiary.We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 pay forthe enteral formula rendered on March 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysthe services can be safely received in other settings, for example: a skilled nursing facility.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 were admitted for altered mental status and a urinary tract infection. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. 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. There isnot 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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe scooter provided on June 15, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forthe scooter. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services received were neither emergent nor urgent and prior authorization was not obtained to seek 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 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 forthe scooter provided on June 15, 2020, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea custom manual wheelchair.You asked the Planto pre-approvethe wheelchair. You say that this is medically necessary.The Plandenied your request. The Plansaysthe recommendiation is to provide the enrollee with a rental lightweight manual wheelchair.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the wheelchair. Our reviewer says that the requested wheelchair is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation reveals a specialty evaluation occurred but does not indicate the medical necessity of the requested specialty chair -K0005. The specialty evaluation recommends a K0003. There is no indication at this time that you require the K0005 over the K0003 to significantly improve ADL performance in the home.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the wheelchair have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea custom manual wheelchair.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychiatry services provided to the enrollee on July 16, 2019.
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 claim was filed 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 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, w
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveNeulasta Onpro (J2505) for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary for the prevention of febrile neutropenia.The Plandenied your request. The Plansaysaccording to the provided medical records, the enrollee is enrolled in a clinical trial.The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services.In this case, you asked the Plan to pre-approve the drug as part of a clinical trial. The Plan does not cover routinecosts associated with qualifying clinical trials.Therefore, we decided that the Plandoes not haveto pre-approveNeulasta Onpro (J2505) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 30, 2020, by an outof-
network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
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 the medical services provided on June 30, 2020,
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are necessary.The Plandenied 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 describedabove.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. 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 thisphysician'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-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on July 22, 2020.
You asked the Plan to waive the copayment for a specialist visit. You say that you should not be charged for phlebotomy services. 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 $30 copayment for each specialist visit. The medical records show that you received specialist services provided on July 22, 2020. Therefore, you are responsible to pay the $30 copayment. You have been asked to pay a $30 copayment for a specialist visit. A specialist 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 a specialist visit provided on July 22, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forambulance services (A0428, A0425) provided on September 20, 2020.You asked the Plan to pay forambulance services. You say that this should be covered.The Plan denied your request. The Plan says this was not billed with an appropriate primary diagnosis.The Plan must follow Medicare rules. Medicare rules say that the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation.We looked at the file and Medicare rules. The billed primary diagnosis, R65.10, is a manifestation code. The underlying condition should be sequenced first; therefore, R65.10 is not an appropriate primary diagnosis. Based on this information, we decided that Medicare rules for coverage of ambulance services have not been met.Therefore, we decided that the Plan does not have to pay forambulance services (A0428, A0425) provided on September20, 2020