Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the copayment for the diagnostic mammography (77066, G0279) provided on January 21, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the copayment has been applied correctly to the service provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $0 coinsurance, copayment, or deductible for covered screening mammograms. One screening mammogram is covered every twelve months for women age 40 and older. 

The Plan says you must pay a $35 copayment for the mammogram provided. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for a screening mammogram. The Plan did not provide proof that you had a previous mammogram less than twelve months prior. Therefore, we decided that the Plan has to waive the copayment for the diagnostic mammography (77066, G0279) provided on January 21, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on January 27, 2021.

You asked the Plan to pay for the ambulance services. You say that you were treated by the medics. The Plan
denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.

The ambulance company did not provide transport services on January 27, 2021. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on January 27,
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for extractions (D7140 x2), and a panoramic radiographic image (D0330) provided on February 10, 2021.

You asked the Plan to pay for extractions (D7140 x2), and a panoramic radiographic image. You say that you were not aware that the provider was out-of-network. The Plan denied your request. The Plan says these services are not covered when performed by an out-of-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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of extractions (D7140 x2), and a panoramic radiographic image have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers available to provide these services. 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 extractions (D7140 x2), and a panoramic radiographic image (D0330) provided on February 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 6, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 81230, 81291, 81231, 81240, 81241, and 81328 are not supported in the medical record. Specifically, when a laboratory assays two or more genes in an enrollee in parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be submitted for the panel. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 6, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the skilled nursing facility (SNF) care provided from February 1, 2021, to February 19, 2021.

You asked the Plan to waive the coinsurance for SNF care. You say that you should not be charged by the Plan since they made you leave the facility before you were ready. The Plan denied your request. The Plan says the claim processed correctly at this time.

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 0% coinsurance per day for days 1-20 and a 10% coinsurance per day for days 21-120 for SNF care. 

You have been asked to pay a cost share of $325 for SNF care ($3250 Medicare allowed amount for days 21-30 x 10% coinsurance). This service falls within the SNF care 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 coinsurance for the skilled nursing facility (SNF) care provided from February 1, 2021, to February 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta.

You asked the Plan to pre-approve Zilretta. The Plan denied your request. The Plan says a repeat injection is
not allowed.

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 Zilretta. Our reviewer says that Zilretta
is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a 75-
year-old female being treated for unilateral primary osteoarthritis of the right knee. She is noted to have
undergone a previous successful Zilretta injection on December 6, 2019, with noted long-lasting benefit. She
notes becoming symptomatic again in the knee secondary to the osteoarthritis. However, there is limited
published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and/or safe
treatment for the noted pathology. Further studies are needed to corroborate the safety and efficacy of this
medication for multiple injections for treatment of knee osteoarthritis. There is no compelling rationale
presented or extenuating circumstances noted to support the medical necessity of this request as an exception.
Therefore, the request for Zilretta is 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 Zilretta have not been met. Therefore, we decided that the Plan does not have to
pre-approve Zilretta.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and an intraoral complete series of radiographic images (D0210) provided on December 21, 2020.

You asked the Plan to pay for a comprehensive oral evaluation, and an intraoral complete series of radiographic images. You say that you want the Plan to pay for these services. The Plan denied your request. The Plan says dental services rendered by an out-of-network provider are 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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation, and an intraoral complete series of radiographic images have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers available to provide these services. 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 a comprehensive oral evaluation (D0150), and an intraoral complete series of radiographic images (D0210) provided on December 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a filling (D2391) provided on December 16, 2020.
You asked the Plan to pay for a filling. You say that you want the Plan to pay for the service. The Plan denied your request. The Plan says you are responsible for services provided by privately contracted providers. The Plan will not reimburse for charges incurred by Medicare Opt Out providers.
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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a filling have not been met. Specifically, services were provided by an Opt Out provider. The Plan does not cover dental services when provided by an Opt Out provider. Therefore, we decided that the Plan does not have to pay for a filling (D2391) provided on December 16, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided the Plan does not have to pay for physician services provided to the enrollee on October 14, 2020.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says due the enrollee's hospice status at the time of service, this claim should be submitted to Original Medicare.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on October 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to a tertiary-level urologist.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the tertiary level of care 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 these services. Our reviewer says that the tertiary level of care is not medically necessary. Our physician reviewer found you have low testosterone. The records do not support that evaluation by a tertiary-level urologist is reasonable and medically necessary. Your care can be provided by a network non-tertiary level urologist. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a referral to a tertiary-level urologist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the root canal (D3320) for tooth #28.

You asked the Plan to pre-approve the root canal (D3320) for tooth #28. You say that you need the root canal. The Plan denied your request. The Plan says the root canal for tooth #28 is not medically necessary.

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 root canal (D3320) for tooth #28 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 root canal (D3320) for tooth #28. Our reviewer says that there is no necessity for a retreatment of the existing root canal fill on tooth #28. Our physician reviewer found the provided records show that tooth #28 has completed root canal treatment, with an adequate fill of the canal space. Our reviewer found that there is no indication that a retreatment of the tooth is necessary, and no clinical notes that indicate an issue with tooth #28 other than it would now require a crown restoration. Root canal treatment is only indicated where there is an active infection of the pulp or recurrent infection of the root canal space in order to preserve a tooth in the dental arch. Our physician reviewer also found that in this instance there is no indication that there is a recurrent infection of the canal space, and the existing root canal fill appears to be adequate. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the root canal (D3320) for tooth #28 have not been met. Therefore, we decided that the Plan does not have to pre-approve the root canal (D3320) for tooth #28.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).

You asked the Plan to pre-approve Prolia. You say that the enrollee has been on Prolia since 2015. You also say that it is not advised that enrollees stop Prolia as it increases the risk for fracture. The Plan denied your request. The Plan says no documentation was provided that indicated the enrollee has ever been osteoporotic. The Plan also says that the enrollee takes calcium and other vitamin D supplements, but there is no documentation that the enrollee has been treated for osteopenia with other medications or has experienced fracture.

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 to pre-approve Prolia. Our reviewer says that Prolia (J0897) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the Dual-energy X-ray absorptiometry (DEXA) scan from 2014 demonstrated mild osteopenia. The enrollee takes calcium and other vitamin D supplements, but there is no documentation that she has been treated for osteopenia with other medications or has experienced an osteoporotic fracture. Our reviewer found that the requested use of Prolia (J0897) is not FDA-approved for the enrollee's diagnosis. Our physician reviewer also found that its use is not supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services (CMS) approved medical journal.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electric scooter.

You asked the Plan to pre-approve the scooter. You say that this is medically necessary, due to an open wound on the bottom of the foot. The Plan denied your request. The Plan says the gait is normal.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

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 scooter. Our reviewer says that the requested scooter is not medically reasonable or necessary. Our physician reviewer found it is not clear that your personal mobility deficit impairs participation in MRADLs, and is unable to be helped by a walker. While you may have the cognitive ability to safely operate the scooter, the documentation does not support that the scooter will significantly improve your ability to participate in MRADLs 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 scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve an electric scooter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the chemodenervation procedure and Botox injection you received at your neurologist's office.

You asked the Plan to waive the cost sharing for the neurology services and Botox injection. You say that you feel that the copay amount is wrong and you have had this procedure previously and it was covered 100%. The Plan denied your request. The Plan says you were charged this cost sharing 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 $50 copayment for services in a specialist's office and 20% coinsurance for Medicare Part B drugs.

You have been asked to pay a $50 copayment for the neurology services and 20% coinsurance for the Botox injection. 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 cost sharing for the chemodenervation procedure and Botox injection you received at your neurologist's office.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular screening testing provided on November 5, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because Medicare denied coverage for all cardiovascular risk assessment panels.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary cardiovascular screening testing provided on November 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), a teeth cleaning (D1110), and an unspecified preventive procedure (D1999) provided on December 16, 2020.

You asked the Plan to pay for a periodic oral evaluation, a teeth cleaning, and an unspecified preventive procedure. You say that you were not aware that the provider had opted out of Medicare. The Plan denied your request. The Plan says you are responsible for services provided by privately contracted providers. The Plan will not reimburse for charges incurred by Medicare Opt Out providers.

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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation, a teeth cleaning, and an unspecified preventive procedure have not been met. Specifically, services were provided by an Opt Out provider. The Plan does not cover dental services when provided by an Opt Out provider. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), a teeth cleaning (D1110), and an unspecified preventive procedure (D1999) provided on December 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #14.

You asked the Plan to pre-approve the crown. You say that you would like the crown for tooth #14 to be approved for coverage. The Plan denied your request. The Plan says this service is not medically necessary.

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 crown 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 crown. Our reviewer says that the documentation provided does not support that a crown restoration for tooth #14 is medically reasonable or necessary. Our physician reviewer found tooth #14 is non-restorable due to the extensive decay extending subosseous and through the furcation.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) for tooth #14.