Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided on May 16, 2021, to May 28, 2021.

You asked the Plan to pay for home health services. You say that records have been submitted to support these services. The Plan denied your request. The Plan says the provider of these services is not enrolled in Medicare.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for home health services provided on May 16, 2021, to May 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medial branch blocks (MBBs) at more than 2 spinal
levels.

You asked the Plan to pre-approve MBBs at more than 2 spinal levels. You say that this procedure is medically
necessary. The Plan denied your request. The Plan says the clinical record does not document unique
circumstances showing medical necessity of MBBs at more than the allowed two levels.

The Plan must follow Medicare rules. Medicare rules say that more than 2 levels of MBBs are only medically
necessary with unique circumstances.

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 MBBs at more than two spinal levels.
Our reviewer says that the requested procedure at more than two levels is not medically necessary. Our
physician reviewer found this 74-year-old woman has chronic axial low back pain. She has had an L5-S1
decompression. She has tried Ibuprofen, Tylenol, Tramadol, Hydrocodone and Flexeril for pain. The LCD
precludes diagnostic MBB at a level of prior surgery. Therefore, this procedure for 3 levels as requested is not
medically reasonable and 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 MBBs at more than 2 spinal levels have not been met. Therefore, we decided
that the Plan does not have to pre-approve medial branch blocks (MBBs) at more than 2 spinal levels.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine eye exam received on May 28, 2021.

You asked the Plan to pay for the routine eye exam. You say that you are being treated for glaucoma and must have regular exams to assess the progression of damage. The Plan denied your request. The Plan says the services received exceed your benefit limit.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one routine eye exam per calendar year. 

We looked at the file and the Plan's rules. Review of the file shows that you received an eye exam on May 28, 2021. You previously received an eye exam on April 22, 2021. This means you had exceeded your benefit limit for eye exams. Based on this information, we decided that the Plan's rules for coverage of the routine eye exam have not been met. Therefore, we decided that the Plan does not have to pay for the routine eye exam received on May 28, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided on June 4, 2021.
You asked the Plan to waive the copayment for physical therapy. You say that the time spent was 20 minutes with no physical therapy now they want a $40 copayment. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment per provider per day for in-network outpatient rehabilitation services.
You have been asked to pay a $40 copayment for physical therapy. Physical therapy falls within the "Outpatient rehabilitation services" benefit category. The records show an evaluation was performed. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for physical therapy provided on June 4, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Evenity.
You asked the Plan to pre-approve Evenity. You say that the medication is necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
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 Evenity. Our reviewer says that the medication is medically necessary. Our physician reviewer found the review has determined that the documentation supports that the Evenity is medically reasonable and necessary for the enrollee. The documentation supports that the Evenity is safe and effective 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 Evenity have been met. Therefore, we decided that the Plan has to pre-approve Evenity.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure.
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have 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 an Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the intracept procedure remains experimental. More research is needed to show safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on July 1, 2021.
You asked the Plan to waive the copayment for the eye exam. You say that you made an appointment for a
yearly checkup to get a new glasses prescription. You say that you should have a $0 copayment for this
appointment, and you asked for this to be rebilled. The Plan denied your request. The Plan says the copayment
applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $45 for
each Medicare-covered exam to diagnose and treat diseases or conditions of the eye from an in-network
provider.
You have been asked to pay a $45 copayment for the eye exam. The eye exam falls within the "Vision care"
benefit category. The records show a medical eye exam was performed and billed. 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 eye exam provided on July 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 72170 provided on June 9, 2021.
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.
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, we have confirmed that code 72170 for the x-ray services is a column II code to column I code 73502. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 72170 provided on June 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the full cast high noble metal crown (D2790) provided on
April 20, 2021.

You asked the Plan to pay for the dental service. You say that your handbook says that crowns are covered at
50% after the $25 deductible is met. You say that the handbook does not state that only some crowns are
covered. You also say that you feel you should not be responsible for the whole cost of the crown. The Plan
denied your request. The Plan says the full cast high noble metal crown is not listed as 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.

Though the Plan offers a dental benefit in excess of Medicare coverage, the full cast high noble metal crown is
not among those covered under this benefit. The Evidence of Coverage clearly states that this certificate will
not pay for dental services that are not listed in the schedule of benefits included with this certificate.
Therefore, we decided that the Plan does not have to pay for the full cast high noble metal crown (D2790)
provided on April 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup (D2950), and crown (D2751), provided on January 28, 2021 and April 1, 2021.

You asked the Plan to pay for the core buildup and crown. You say that the service should be covered. The Plan denied your request. The Plan says you did not use a dentist in the Plan's dental network.

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 core buildup (D2950), and crown (D2751), provided on January 28, 2021 and April 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Teprotumumab-trbw (Tepezza).
You asked the Plan to pre-approve Tepezza. The Plan denied your request. The Plan says Tepezza is not medically necessary. The Plan also says that the records did not say if the enrollee has active eye disease because of Grave's disease.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for Food and Drug Administration (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 Tepezza. Our reviewer says that Tepezza is not medically reasonable and necessary for the enrollee. Our physician reviewer found based on the medical records provided and the Medicare-approved major drug compendia, there is no documentation that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee as defined by Medicare criteria and the health plan's prior authorization criteria as records do not clearly document clinically active thyroid eye disease. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Tepezza have not been met. Therefore, we decided that the Plan does not have to pre-approve Teprotumumab-trbw (Tepezza).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgery on your prostate by a special procedure called embolization.
You asked the Plan to pre-approve surgery on your prostate by a special procedure called embolization. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have 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 surgery on your prostate by a special procedure called embolization. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found prostatic arterial embolization (PAE) is considered an experimental technique to treat symptomatic benign prostatic hyperplasia (BPH). Very limited studies have demonstrated possible short-term safety and efficacy. The most recent American Urological Association (AUA) guidelines do not recommend this procedure outside of a clinical trial setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of surgery on your prostate by a special procedure called embolization have not
been met. Therefore, we decided that the Plan does not have to pre-approve surgery on your prostate by a special procedure called embolization
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rocklatan Dro.
You asked the Plan to pre-approve Rocklatan Dro. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
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 Rocklatan Dro.
Benefits for Rocklatan Dro 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the scaling and root planing (D4341)
for the lower left quadrant provided on May 19, 2021.
You asked the Plan to pay an additional amount for the dental service. You say that the services should be
covered in full. The Plan denied your request. The Plan says there is a maximum allowance of $1,500 every
year. The Plan also says that the maximum allowance was exhausted while processing this claim.
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 the dental service have not been met. Specifically, the file shows that the maximum allowance was
exhausted while processing this claim. Additionally, the record shows that the Plan confirmed with the provider
that the services were billed correctly. Therefore, we decided that the Plan does not have to pay an additional
amount for the scaling and root planing (D4341) for the lower left quadrant provided on May 19, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services provided April 30,
2021 to July 26, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you are requesting that
payments due and ongoing problem expenses be absorbed by the Plan as it was entirely medical errors and that
the Plan assist with the expenses occurred because of these errors. 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 $240
copayment for each ambulance trip. You had 2 ambulance trip(s). The Plan charged you $240 for each of these
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 ambulance services provided April 30, 2021
to July 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis provided on May 20, 2021.
You asked the Plan to pay for the prophylaxis. You say that you needed a dentist closest to where you live because you cannot drive far. You say that you were told to go to this office, and you need to be reimbursed $96. The Plan denied your request. The Plan says out-of-network dental services 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. Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the prophylaxis provided on May 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for muscle, myocutaneous, or fasciocutaneous flaps (15733,
15733-59) and the surgical preparation or creation of recipient site (15004) provided on July 27, 2020.
You asked the Plan to pay for muscle, myocutaneous, or fasciocutaneous flaps and the surgical preparation or
creation of recipient site. You say that these codes are supported. The Plan denied your request. The Plan says
these codes are not documented.
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 15733 is muscle, myocutaneous, or fasciocutaneous flap;
head and neck with named vascular pedicle (ie, buccinators, genioglossus, temporalis, masseter,
sternocleidomastoid, levator scapulae). The definition of 15004 is surgical preparation or creation of recipient
site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of
scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first
100 sq cm or 1% of body area of infants and children.
We asked our coder 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 muscle, myocutaneous, or fasciocutaneous flaps and the
surgical preparation or creation of recipient site. Our reviewer says that these codes are not supported. Our
reviewer found the operative report describes advancement flaps rather than flaps described by code 15733.
The operative report also does not document surgical preparation of recipient site by excision, and therefore
code 15004 cannot be confirmed as performed.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of muscle, myocutaneous, or fasciocutaneous flaps and the surgical preparation or
creation of recipient site have not been met. Therefore, we decided that the Plan does not have to pay for
muscle, myocutaneous, or fasciocutaneous flaps (15733, 15733-59) and the surgical preparation or creation of
recipient site (15004) provided on July 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 19, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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 the office visit provided on January 19, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on January 29, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this screening test is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on January 29, 2021.