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

We decided that the Plan does not have to pre-approve an upper partial denture (D5225).

You asked the Plan to pre-approve an upper partial denture. You say that you want the Plan to cover the service. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of once every 60 months.

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 an upper partial denture have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on October 30, 2018. Therefore, we decided that the Plan does not have to pre-approve an upper partial denture (D5225).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.

You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that this item is medically necessary due to the occasional pain from finger testing. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on October 19, 2020.

You asked the Plan to pay for the testing services. You say that physicians send specimens to the lab for testing. The Plan denied your request. The Plan says the billed codes cannot be verified.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.

We looked at the file and the rules. The billed claim shows the place of service as an independent lab. The records do not indicate the specimen was obtained at an independent lab. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on October 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro orthotic device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of this device in the setting of unilateral left upper extremity impairment following a stroke has not demonstrated in the peer-reviewed literature.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro orthotic device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your request. The Plan says the medical information provided indicates that you are unable to safely transfer into the scooter and operate it safely in the home.
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 there is no objective physical exam documents included in the submitted records. There is no detailed neuromuscular or gait evaluation and it is not clear that your mobility deficit is unable to be helped by a walker, cane, or manual wheelchair. The face-to-face exam states that you do not have the strength to operate a manual wheelchair, but
there is no detailed objective strength or neuromuscular exam. There is no objective home evaluation indicating this scooter can be safely maneuvered in the home. You are noted not to have sufficient vision to safely operate the scooter. 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 a power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oxygen medical equipment to be provided by an out of
network (OON) provider.

You asked the Plan to pre-approve oxygen medical equipment. You say that you would like this oxygen
generator. The Plan denied your request. The Plan says this equipment can be provided 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 oxygen medical equipment to be provided by an out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane.
You asked the Plan to pre-approve Durolane. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says step therapy criteria have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Durolane. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. In this case, the patient has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) 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 Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on January 7, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that payment cannot be made for codes with a PC/TC indicator of 5 when performed in the inpatient hospital or outpatient hospital setting. We looked at the file and Medicare rules. Billed procedure code 69209 (removal of impacted cerumen) has a PC/TC indicator of 5. The file shows that the services were performed in the outpatient hospital setting; therefore, payment cannot be made. 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 surgical services rendered on January 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve in-network benefit exception for services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve in-network benefit exception. You say that your health has been good until 01/28/2021 with a visit to the ER with a Lupus Flare. You would like to see this doctor because he is familiar with your case. The Plan denied your request. The Plan says you can receive your care from either an in-network or an out-of-network provider.

The plan must follow Medicare rules. The Rules say that this plan will generally cover your medical care as long as the care you receive is considered medically necessary and you receive your care from a provider who is eligible to provide services under Original Medicare. As a member of the Plan, you can receive your care from either an in-network provider or an out-of-network provider. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The health plan contract specifically says that if you use an out of network provider, your share of costs for your covered services may be higher. 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 in-network benefit exception for services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on November 17, 2020.
You asked the Plan to waive the copayment for an office visit. You say that this was an annual wellness visit and you should not be responsible for 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 there are no cost-sharing charges for annual wellness visits.
Your contract with the Plan also clearly says that you must pay a $10 copayment for primary care provider visits. The medical records show that you had an office visit on November 17, 2020 that went beyond an annual wellness visit. Therefore, you are responsible to pay the $10 copayment. You have been asked to pay a $10 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an office visit provided on November 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodontal maintenance (D4910) provided on March 9, 2021.
You asked the Plan to pay more for the dental service. You say that this service should be covered. The Plan denied your request. The Plan says periodontal maintenance is covered with a 50% coinsurance. The Plan says that there is a $25 deductible per calendar year for covered dental services. The Plan also says that payment will not be made for covered services until the deductible has been met.
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 and periodontal maintenance is listed as covered, payment cannot be applied to covered services until the $25 deductible has been met for the calendar year. Therefore, we decided that the Plan does not have to pay more for the periodontal maintenance (D4910) provided on March 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cataract removal and lens placement.
You asked the Plan to pre-approve extracapsular cataract removal with insertion of intraocular lens prosthesis (66982, 66984). You say that the enrollee needs cataract surgery. The Plan denied your request. The Plan says given the documentation the enrollee does not meet the guidelines for the procedure.
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 no clear documentation of symptoms. Based on this information, we decided that Medicare rules for coverage of extracapsular cataract removal with insertion of intraocular lens prosthesis (66982, 66984) have not been met. Therefore, we decided that the Plan does not have to pre-approve cataract removal and lens placement.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a full mouth debridement (D4355) provided on March 8, 2021.
You asked the Plan to pay for a full mouth debridement. You say that you want the Plan to pay for the service. The Plan denied your request. The Plan says the service at issue is not a covered 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 a full mouth debridement (D4355) provided on March 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from January 8, 2021, to January 16, 2021.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the denied 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 $345 copayment for days 1-5 for inpatient hospital care. You had an inpatient hospital stay from January 8, 2021, to January 16, 2021. Therefore, you are responsible to pay a $345 copayment for days 1-5 (January 8, 2021, to January 12, 2021). The total amount you owe is: $345 (copayment) x 5 (inpatient days) = $1,725.
You have been asked to pay the total copayment amount of $1,725 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 copayment for an inpatient hospital stay from January 8, 2021, to January 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a telehealth visit provided on March 11, 2021.

You asked the Plan to waive the copayment for a telehealth visit. You say that you disagree with the charges because you only called to get advice. 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 primary care provider visits, including telehealth services. 

You have been asked to pay a $10 copayment for a telehealth visit. A telehealth visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a telehealth visit provided on March 11, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0429) provided on March 15, 2021.

You asked the Plan to pay for ambulance services. You say that the QL modifier is required because the enrollee died. The Plan denied your request. The Plan says this should be billed with A0428.

The Plan must follow Medicare rules. Medicare rules say that in the case where the beneficiary was pronounced dead after the ambulance is called but before the ambulance arrives at the scene, providers report the A0428 (BLS) HCPCS code. 

We looked at the file and Medicare rules. The service at issue was billed with A0429, but A0428 is required in this circumstance. Based on this information, we decided that Medicare rules for coverage of ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services (A0429) provided on March 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hymovis.

You asked the Plan to pre-approve Hymovis. The Plan denied your request. The Plan says the enrollee has not met 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 Hymovis. Our reviewer says that Hymovis is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered, or that the plan's required drugs 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 Hymovis have not been met. Therefore, we decided that the Plan does not have to pre-approve Hymovis.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection of aflibercept (a Medicare Part B drug) provided on February 26, 2021.
You asked the Plan to waive the coinsurance for Part B drug. You say that you thought you were disenrolled from this plan before February 2021. The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct.
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 Part B drug. The allowed amount of this injection is $1,843.51, resulting in a coinsurance amount of $368.70.
You have been asked to pay 20% coinsurance for Part B drug. 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 an injection of aflibercept (a Medicare Part B drug) provided on February 26, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient mental health visits provided from February 25, 2021, through April 29, 2021.

You asked the Plan to waive the copayment for the outpatient mental health visits. You say that you were told the copayment would remain $20 through 2021. You say that you were never informed whether the provider was in-network or not and the Plan should pay the difference. The Plan denied your request. The Plan says the copayments 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 $35 copayment per provider, per day for each Medicare-covered individual visit with an out-of-network psychiatrist.

You have been asked to pay a $35 copayment for each outpatient mental health visit. The total amount you owe is $350 ($35/visit x 10 visits = $350). The outpatient mental health visits fall within the "Outpatient mental health care" benefit category. The records show the provider is an out-of-network provider. 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 outpatient mental health visits provided from February 25, 2021, through April 29, 2021.