Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction services provided on March 1, 2021.

You asked the Plan to pay for the refraction services. You say that there is no copay for a diabetic eye exam. The Plan denied your request. The Plan says refractions are not covered by your plan.

The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear.

The refraction services you asked the Plan to pay for are considered routine vision services. These services are not covered by Medicare or your plan. Therefore, we decided that the Plan does not have to pay for the eye refraction services provided on March 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

You asked the Plan to pre-approve Prolia. You say that you would like the plan to reconsider their denial. The
Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the
documentation does not support that the enrollee meets step therapy criteria for the requested drug. Our
physician reviewer found the enrollee has a history of osteoporosis. The documentation does not support that
the enrollee has tried and failed Zoledronic Acid. The documentation does not indicate that the Plan's required
drug would likely be less effective and/or likely have adverse effects 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 Prolia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional features for a prosthetic leg.
You asked the Plan to pre-approve the additional features. You say that this is medically necessary. The Plan denied your request. The Plan says this request for a replacement prosthesis with a microprocessor knee and foot does not meet Medicare criteria as reasonable and 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 the additional features. Our reviewer says that the requested additional features are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation is not consistent that the enrollee is a K3 ambulator given her history of not using a prosthesis since 2011, use of a cane with prior prosthesis, multiple medical comorbidities including back and shoulder issues needing physical therapy and pain medications. 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 additional features have not been met. Therefore, we decided that the Plan does not have to pre-approve additional features for a prosthetic leg.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan, Supartz FX, Visco-3.
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 services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has bilateral knee osteoarthritis. The records show that he has only undergone cortisone injections to both knees. There is no documentation of any conservative medical therapy or trial of physical therapy. The requested services are therefore not reasonable or 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 not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan, Supartz FX, Visco-3.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging services rendered on December 21, 2020.
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 procedure code 76376 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 76376 is 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation. We find that CPT code 76376 is not supported in the medical record. Specifically, there is no documentation of
3D rendering with interpretation and reporting of CT, MRI, ultrasound, or other tomographic modality. 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 for the imaging services rendered on December 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on October 14, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that prior authorization was not obtained by a participating provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 lab work provided on October 14, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (80299, 80307, 82542) provided on September 11, 2020 by an out of network (OON) provider.
You asked the Plan to pay for OON drug testing. You say that most in-network providers cannot perform such complex testing. The Plan denied your request. The Plan says this was not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 drug testing (80299, 80307, 82542) provided on September 11, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown - porcelain/ceramic (D2740).
You asked the Plan to pre-approve the crown. You say that you need a previous crown corrected due to the wrong color being used. The Plan denied your request. The Plan says you have exhausted your benefit for this procedure for the 2021 plan year.
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 one crown procedure code per calendar year. We looked at the file, and Medicare rules. The Plan has submitted evidence that you last received, and the Plan covered, a crown on March 8, 2021. Your benefit for this procedure has been exhausted for the 2021 plan year. 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 the crown - porcelain/ceramic (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the therapeutic parenteral drug, single administration
(D9610), and the interim partial denture (including retentive/clasping materials, rests, and teeth), maxillary
(D5820).
You asked the Plan to pre-approve the dental services (D9610, D5820). You say that these services should be
covered by the Plan. The Plan denied your request. The Plan says the requested services are not covered under
your supplemental benefit.
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 the
therapeutic parenteral drug, single administration (D9610), and the interim partial denture (including
retentive/clasping materials, rests, and teeth), maxillary (D5820).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) provided September 14, 2020.

You asked the Plan to pay for the chiropractic services. You say that please see attached medical records and review documentation to support all services rendered. Please review and reprocess this date of service for reimbursement. The Plan denied your request. The Plan says the criteria has not been met since the chiropractic services was performed with a mechanical device with onboard computer assistance, not using manual means of therapy.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) provided September 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a participating provider on February 21, 2018.
You asked the Plan to waive the copayment for a specialist office visit. You say that you paid your copayment at the beginning of the visit. The Plan denied your request. The Plan says the correct copayment has been applied.
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 physician/practitioner services/specialist. You have been asked to pay a $40 copayment for a specialist office visit. The correct copayment has been applied to the services that were provided. A specialist office visit falls within the physician/practitioner
services/specialist 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 office visit provided by a participating provider on February 21, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion to be provided by an OON provider.
You asked the Plan to pre-approve the OON second opinion. You say that the enrollee needs a second opinion
on the pathology sample because the diagnosis is uncertain. The Plan denied your request. The Plan says the
services being requested are available within the Plan 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
a second opinion to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310), endodontic therapy, molar tooth (excluding final restoration) (D3330) and cone beam computed tomography (CT) capture and interpretation with field of view of both jaws; with or without cranium (D0367) provided February 2, 2021.
You asked the Plan to provide additional payment for the dental consultation, endodontic therapy and cone beam CT scan. You say that neither you nor your provider were aware the provider was out-of-network and therefore you should not be required to pay the additional cost. The Plan denied your request. The Plan says you are responsible for the deductible and your coinsurance plus the difference between the allowed amount
and the total cost for services provided by an OON provider. Additionally, the cone beam CT scan is not a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. You are responsible for a $100 yearly deductible for comprehensive dental services. After the deductible is met you have a 30% coinsurance for dental consultations and endodontic therapy. For services provided OON you are responsible for the difference between the allowed amount and the total cost billed by the OON provider. Cone beam CT scans are not a covered service under your benefits. We looked at the file and Medicare rules. At the time of the services, you still had $100 remaining in your deductible. The Plan provided documentation showing they you are responsible for 30% of the cost of the dental consultation and endodontic therapy plus your deductible. Though the Plan provides dental benefits in excess of Medicare coverage, the cone beam CT scan is not among those services covered. Therefore, we decided that the Plan does not have to provide additional payment for the consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310), endodontic therapy, molar tooth (excluding final restoration) (D3330) and cone beam computed tomography (CT) capture and interpretation with field of view of both jaws; with or without cranium (D0367) provided February 2, 2021.
Your complaint about being unaware that the provider was OON is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (CPT 58874) provided to the enrollee on January 7, 2021.
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 CPT 58874 was not billed with the required device.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 58874 is "Transperineal placement of biodegradable material, peri-prostatic, single or multiple injection(s), including image guidance, when performed." 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 pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the documentation supports that CPT code 55874 (Transperineal placement of biodegradable material, peri-prostatic, single or multiple injection(s), including image guidance, when performed) is not billed correctly.
Effective 1/1/2015, the submission of a device-dependent procedure requires that a device be submitted on the same claim/day. If any device-dependent procedure is submitted without a code for a device on the same claim with the same date of service, the claim is returned to the provider. The Medicare rule for payment of the claim has not been met 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 services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (CPT 58874) provided to the enrollee on January 7, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section 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 care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found there are no services offered at a SNF that are
not offered at an inpatient rehab facility. Admission to a SNF for inpatient skilled rehab services is not
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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (97110) provided December 11, 2020.
You asked the Plan to pay for the therapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the CPT code billed.
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 code 97110 is not supported in the medical record. Specifically, the records show the service was provided in the home setting. There is a more appropriate CPT code to describe these services in this setting (G0157). Based on this information, we decided that Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan does not have to pay for therapy services (97110) provided December 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for continuity of care with an out-of-network
provider for pain injections.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says although it is acknowledged that there are a lot of medical problems, there are a number
of in-network providers available.
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 referral. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found there is no medical reason to an out-of-network provider. While complex, this care can be done in-network.
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 referral have not been met. Therefore, we decided that the Plan does not
have to pre-approve a referral for continuity of care with an out-of-network provider for pain injections.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on January 24, 2020.
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 claim was billed incorrectly.
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 a
laboratory setting; 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 for the drug testing
rendered on January 24, 2020.