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

We decided that the Plan does not have to pre-approve a consultation to be provided by an endodontist.
You asked the Plan to pre-approve the consultation. You say that due to an x-ray showing a periapical lucency at the apex of tooth #3, you would like the enrollee to be evaluated by an endodontist. You also say that the enrollee may need to have a re-treatment of a root canal. The Plan denied your request. The Plan says they only cover dental services provided by a participating general dentist. The Plan also says they do not cover dental services performed by an oral surgeon or endodontist.
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 when they are not performed by a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a consultation to be provided by an endodontist.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on September 23, 2019.
You asked the Plan to waive the copayment for the colonoscopy. You say that a screening colonoscopy is paid in full. You say that the colonoscopy should be paid for. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $450 copayment for each Medicare covered surgical procedure in an outpatient hospital facility. You have been asked to pay a $450 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that polyps were removed, which is considered a surgical procedure. 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 colonoscopy provided on September 23, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora laryngoscopy provided on October 7, 2019.You asked the Plan to waive the copayment fora laryngoscopy. You say that you disagree with the outpatient surgical procedures.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 $290 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay the allowed amount of $186.68, which is less than the $290 copayment for a laryngoscopy. A laryngoscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 fora laryngoscopy provided on October 7, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe office visit and laboratory services provided on August 1, 2019.You asked the Plan to waive the coinsurance forthe office visit and laboratory services. You say that you previously saw the same provider and only paid a $40 copayment. You say that this claim shouldn't be charged with coinsurance.The Plan denied your request. The Plan says the coinsurance 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 30% coinsurance of the allowed amount for point of service (POS)services. Point of Service coverage is available for out-of-network office visits and lab services. You have been asked to pay a total of $145.75 for the office visit and laboratory services. The office visit and laboratory services falls within the "Point of Service (POS) coverage" benefit category. The records show that the provider is out-of-network. 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 coinsurance for the office visit and laboratory services provided on August 1, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance foroutpatient surgery provided on May 23, 2018.You asked the Plan to waive the coinsurance foroutpatient surgery. You say that you still had a bunion on your foot after surgery. You say that the doctor should not have been paid.The Plan denied your request. The Plan says the coinsurance 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% coinsurance per service for outpatient surgical services at an in-network hospital.You have been asked to pay a total of $305.79 for outpatient surgery. Outpatient surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that surgery was performed. 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 coinsurance foroutpatient surgery provided on May 23, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the mandibular partial denture (D5214).
You asked the Plan to pre-approve the mandibular partial denture. You say that you lost your partial in November 2019. You also say that you are suffering with minimal teeth and cannot properly chew your food. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.
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, partial dentures are limited to one procedure every five plan years. The record shows that you received a partial denture on March 26, 2019 and your partial denture benefit is now exhausted. Therefore, we decided that the Plan does not have to pre-approve the mandibular partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two prefabricated abutments (D6056 x2) and two abutment supported porcelain fused to metal crowns (D6061 x2).
You asked the Plan to pre-approve the prefabricated abutments and abutment supported porcelain fused to metal crowns. You say that this enrollee has already gotten their dental implants placed but the treatment was not able to be completed in 2019. You also say that leaving the implants exposed or left un-restored may create serious health risks for this enrollee. The Plan denied your request. The Plan says these services are not covered under the enrollee's benefit package.
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 two prefabricated abutments (D6056 x2) and two abutment supported porcelain fused to metal crowns (D6061 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe first intraoral periapical x-ray provided on November 20, 2019.You asked the Plan to pay forthe first intraoral periapical x-ray. You say that this is a simple x-ray that should be covered.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 only x-rays that are covered by the Plan are bitewing x-rays.Therefore, we decided that the Plan does not have to pay forthe first intraoral periapical x-ray provided on November 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent for enrollee.You asked the Plan to pre-approve Dupixent. You say that the enrollee is not a good candidate for suggested alternatives.The Plan denied your request. The Plan says Dupixent to be taken at home is not covered under the Part 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 Dupixent for enrollee.Benefits for Dupixent 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 pre-approve an office visit to be provided by an out-of-network provider at the in-network rate.
You asked the Plan to pre-approve the out-of-network office visit at the in-network rate. You say that you have used this doctor in the past and would like to continue. The Plan denied your request. The Plan says there are in-network providers that can provide the service at issue at the in-network rate.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that using out-of-network providers may result in higher costs. 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. Therefore, we decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network provider at the in-network rate.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CPAP supplies to be provided by an out of network provider.You asked the Plan to pre-approve the CPAP supplies from and out-of-network supplier. You say that you want to continue to get your supplies from Keene Medical Supplies.The Plan denied your request. The Plan says the supplies are available in network.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve the CPAP supplies to be provided by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on April 2, 2019.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 claim was not billed correctly.The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for an independent laboratory; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11.Therefore, we decided that the Plan does not have to pay forthe drug testing rendered on April 2, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal fusion surgery.You asked the Plan to pre-approve spinal fusion surgery. The Plan denied your request. The Plan says this is 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 spinal fusion surgery. Our reviewer says that the requested spinal fusion surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no spinal instability, fracture, or concern for tumor. There is no severe neuro deficit. Surgery is not medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on thisinformation, we decided that Medicare rules for coverage of spinal fusion surgery have not been met.Therefore, we decided that the Plan does not have to pre-approve spinal fusion surgery.
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 the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on January 9, 2020 with abdominal pain. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. All medically necessary services are being provided in the current acute care setting. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forhome health services (S9122) provided on February 1, 2019 through September 30, 2019.You asked the Plan to pay for the home health services. You say that according to the member's Plan, aides are covered and none of the agencies listed offer this service. The Plan denied your request. The Plan says this provider is not Medicare-certified and per the member's EOC, the provider must be eligible to participate in Medicare.The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items or services from either Medicare or a Medicare beneficiary, a provider or supplier must be enrolled in the Medicare program. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Specifically, the record indicates that this provider is not Medicare-certified. Therefore, we decided that the Plan does not have to pay for home health services (S9122) provided on February 1, 2019 through September 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea pulse generator system for tympanic treatment.You asked the Plan to pre-approvea pulse generator system for tympanic treatment (E2120). You say that the enrollee has a progressive and debilitating disorder and needs this minimally invasive option.The Plan denied your request. The Plan says this treatment for the enrollee's disorder is 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 looked at the file and Medicare rules. There is not enough scientific evidence to show a benefit from this treatment. Based on this information, we decided that Medicare rules for coverage of a pulse generator system for tympanic treatment (E2120) have not been met.Therefore, we decided that the Plan does not have to pre-approvea pulse generator system for tympanic treatment.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveGammagard.You asked the Plan to pre-approvethese services. You say that the services are medically necessary.The Plan denied your request. The Plan says that the diagnosis is not covered.The Plan must follow Medicare rules. Medicare rules say that Gammagard is covered for specific indications.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 medically necessary. Our physician reviewer found the enrollee has a diagnosis of myasthenia gravis. The Central Neurology note dated March 2, 2020 documents that the enrollee was diagnosed with this neurological disorder about seven weeks prior, following surgery. Intravenousimmune globulin (IVIG) was administered with improvement of her symptoms. It is documented that the enrollee is in an exacerbated state, with difficulty breathing, and difficulty chewing food and swallowing. Her speech is slurred. There is evident weakness on physical exam. The enrollee meets the criteria for coverage of Gammagard, as it is documented that the enrollee has had rapid progression of the disease, did not tolerate prednisone, and is symptomatic while on Mestinon. Gammagard is reasonable and medically necessary at this time.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 been met.Therefore, we decided that the Plan has to pre-approveGammagard.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on June 27, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records; therefore the billed code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on June 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea pneumatic compression device (E0652) and accessory items (E0667).You asked the Plan to pre-approvea pneumatic compression device and accessories. The Plan denied your request. The Plan says Medicare coverage criteria have not been met.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to pre-approvea pneumatic compression device (E0652) and accessory items (E0667)
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One injections.
You asked the Plan to pre-approve the Synvisc-One injections. You say that this clinic does not use Orthovisc or Monovisc due to the high cost and low reimbursement for these agents. The Plan denied your request. The Plan says coverage is limited to Monovisc or Orthovisc unless there is a medical reason that it would not be appropriate for the enrollee.
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 injections. Our reviewer says that the requested drug is not considered medically reasonable and necessary based on the step therapy rules. Our physician reviewer found the enrollee has a diagnosis of Unilateral primary osteoarthritis of the right knee. There is no evidence that the enrollee has tried and failed the preferred medications. The documentation does not support that Orthovisc and Monovisc would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the Synvisc-One injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One injections.