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

We decided that the Plan has to pre-approve crowns (D2740) for tooth #'s 3 and 15 and core buildups, including any pins when required (D2950) for tooth #'s 3 and 15.
You asked the Plan to pre-approve the crowns and core buildups. You say that tooth #3 has large existing decay on mesial lingual buccal, which is broken, with visible fracture lines. You also say that tooth #15 has buccal occlusal decay. The Plan denied your request. The Plan says that these services are 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 crowns and core buildups 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 crowns and core buildups. Our reviewer says that the coronal breakdown exhibited by teeth #'s 3 and 15 meets the criteria for coverage for crown restorations (D2740) and core buildups (D2950). Our physician reviewer found the review of the enrollee's dental record and radiographs indicate that tooth #'s 3 and 15 both exhibit significant coronal breakdown due to caries and fracture, which warrants crown restorations and core buildups to restore the teeth to adequate masticatory function. 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 crowns and core buildups have been met. Therefore, we decided that the Plan has to pre-approve crowns (D2740) for tooth #'s 3 and 15 and core buildups, including any pins when required (D2950) for tooth #'s 3 and 15.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray and does not have to waive the coinsurance for a Medicare Part B drug provided on September 21, 2020.
You asked the Plan to waive the copayment for an X-ray and to waive the coinsurance for a Medicare Part B drug. You say that you thought that you would only owe an office copayment and disagree with the additional charges. 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 $10 copayment for X-rays. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B drugs. You received an X-ray on September 21, 2020. Therefore, you are responsible to pay the $10 copayment. You received a Medicare Part B drug on September 21, 2020. The total allowed amount is $6.09 and 20% of that is $1.22. The total amount you owe is: $11.22. You have been asked to pay the total amount of $11.22 for an X-ray and a Medicare Part B drug. An X-ray falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. A Medicare Part B drug falls within the Medicare Part B drugs 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 an X-ray and does not have to waive the coinsurance for a Medicare Part B drug provided on September 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services you received
from September 1, 2020, to September 2, 2020.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you believe this
copayment was charged incorrectly because this was a network facility. The Plan denied your request. The Plan
says You were charged this copayment correctly. The Plan says that your appeal for other dates of service and
other service types will be handled separately.
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 $360
copayment per day for days 1-5 for inpatient hospital care.
Records show that you were an inpatient for one day from September 1, 2020, to September 2, 2020. You have
been asked to pay a $360 copayment for the inpatient hospital services. 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 inpatient hospital services you received from September 1, 2020, to September 2, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound provided by an out-of-network provider on December 2, 2020.
You asked the Plan to pay for the ultrasound. You say that you submitted the report and office notes for processing of the claim. The Plan denied your request. The Plan says this provider is not a network provider with the Plan.
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 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 ultrasound provided by an out-of-network provider on December 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the facet injection procedure you had at an outpatient hospital facility on December 29, 2020.
You asked the Plan to waive the copayment for the facet injection procedure. You say that you had to have this procedure done at an out-of-network facility, but you should only have to pay the in-network rate. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that although you were originally quoted 45-50% coinsurance, you have actually only be charged a lower copayment at the in-network level.
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 $295 copayment for surgery in an outpatient hospital facility. You have been asked to pay a $295 copayment for the facet injection procedure. The facet injection procedure falls within the surgery in an outpatient hospital facility benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the facet injection procedure you had at an outpatient hospital facility on December 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for laboratory services provided on November 5, 2020.
You asked the Plan to waive the deductible for laboratory services. You say that you disagree with the charges because the Plan did not pay anything. 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. Your contract with the Plan says that there is a $300 deductible for outpatient diagnostic tests and therapeutic services and supplies. Your contract with the Plan also clearly says that after the $300 deductible has been met, enrollee's must pay a $10 copayment for laboratory tests. You received laboratory services on November 5, 2020. The record shows that you had only paid $110.42 toward the $300 deductible prior to receiving the services. Therefore, you are responsible to pay the remaining deductible balance of $189.58. Now that the $300 deductible has been met, you are also responsible to pay a $10 copayment. The total amount you owe is $199.58. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible for outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time laboratory services was received on November 5, 2020. Therefore, we decided that the Plan does not have to waive the deductible for laboratory services provided on November 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D0470, D2970, D4263, D4266).
You asked the Plan to pay for the dental services. You say that the requested services were necessary. 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 pay for the dental services (D0470, D2970, D4263, D4266).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Anoro Ellipta Aer.
You asked the Plan to pre-approve Anoro Ellipta Aer. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Anoro Ellipta Aer is not covered under the enrollee's Medicare 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 Anoro Ellipta Aer.
Benefits for Anoro Ellipta Aer 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 pay for physician services provided by an out-of-network provider on September 23, 2020.
You asked the Plan to pay for the physician services. You say that authorization should not be needed under telemedicine. You say that there are other dates of services that were paid without requiring authorization. The Plan denied your request. The Plan says this provider is not a network provider with the Plan.
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 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 physician services provided by an out-of-network provider on September 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on August 6, 2020.
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you disagree with the charges. 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 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug on August 6, 2020. The total allowed amount is $1,366.27 and 20% of that is $244.40. You have been asked to pay the total coinsurance amount of $244.40 for a Medicare Part B drug. A Medicare Part B drug falls within the Medicare Part B prescription drugs 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 a Medicare Part B drug provided on August 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 14, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says it is important to know which providers are part of our network because, with limited exceptions, while the enrollee is a member of our Plan the enrollee must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available, out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers.
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 did not pre-approve the laboratory 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 laboratory services provided on October 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that you are learning how to walk again and that is why you need to go to therapy. The Plan denied your request. The Plan says you exhausted your benefit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at your request, the records in the case file, and the rules. Based on this information, you exhausted your 40 one-way trips benefit. The 41st trip and beyond is not a covered benefit. Your 2021 EOC states that enrollees must pay a $0 copayment for up to 40 one-way trips to plan-approved locations every year. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22870, 22869).
You asked the Plan to pre-approve the interspinous spacer placement. You say that the service is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 interspinous spacer placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the interspinous spacer device is experimental. More research is needed to show safety and efficacy of the device. 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 interspinous spacer placement have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement (22870, 22869).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional physical therapy sessions (CPT code 97168), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says based on the enrollee's clinical information their pain and ability to move has not greatly changed with physical therapy. The Plan states the documentation does not support the enrollee's ongoing need for the unique skills of a physical therapist.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee has had prior therapy and the records do not demonstrate that their functional level requires the unique skills of a professional therapist to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. The enrollee has been instructed in adaptive equipment, and a home exercise program. Mobility function score was 11 with 12 as the highest. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 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 pre-approve ten (10) additional physical therapy sessions (CPT code 97168), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on December 9, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says 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 physician services provided on December 9, 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 periodontal scaling and root planing-four or more teeth per quadrant (CPT code D4341) (quadrants 30-LL and 40-LR).
You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says you exhausted your 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. Review of the file show that you received CPT Code D4341 x2 (quadrants 30-LL and 40-LR) on December 10, 2020. The health plan contract says one (1) of (D4341, D4342) per thirty-six (36) Month(s) per patient, per quadrant. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing-four or more teeth per quadrant (CPT code D4341) (quadrants 30-LL and 40-LR).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty) (CPT code 27447), for the enrollee.
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says no additional imaging has been performed or submitted for review regarding this appeal since the previous X-ray of Right Knee performed February 2, 2020. The Plan states there is no documentation of any medications attempted for pain control. The Plan states the enrollee has received joint injection with great relief of the left knee in the past. There is no clinical update regarding enrollee's response to right knee injection performed December 3, 2020.
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 service. Our physician reviewer found detailed documentation is not evident regarding results from the right knee cortisone injection on December 3, 2020. Furthermore, on this date the enrollee noted they wished to delay the right total knee arthroplasty. Detailed documentation is not evident regarding any update from this decision. Issues regarding inability to perform activities of daily living have not been documented. Detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. Therefore, the request for right total knee arthroplasty 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 the service have not been met. Therefore, we decided that the Plan does not have to pre-approve arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty) (CPT code 27447), for the enrollee.