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

We decided that the Plan does not have to pay for the core build up (D2950), and crown (D2790) for tooth # 31 provided on November 2, 2021.

You asked the Plan to pay for the dental services. You say that you were advised by an agent that you could get 2 more crowns covered if you started a new plan. You say that you received a new card in May 2021. You also say that the crown should be covered. The Plan denied your request. The Plan says core build up is not listed as a covered service. The Plan says that 2 crowns are covered per calendar year. The Plan also says that the frequency limit has been exceeded.

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 core build up is not among those covered under this benefit. Additionally, 2 crowns are covered per calendar year. The record shows that the Plan paid for 2 crowns that you received on April 14, 2021. Therefore, we decided that the Plan does not have to pay for the core build up (D2950), and crown (D2790) for tooth # 31 provided on November 2, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport
(A0998) provided on August 29, 2021.
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you
declined the use of the ambulance and preferred to have your wife drive you to the hospital. You also say that
this was a severe emergency, and you had no time to check with your insurance. The Plan denied your request.
The Plan says this service is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on August 29, 2021. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no
transport (A0998) provided on August 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Otezla tablet.
You asked the Plan to pre-approve Otezla. You say that this should be covered. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.
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 Otezla tablet.
Benefits for Otezla 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Omeprazole caplet 40mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this self-administered drug does not fall under Part B 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 Omeprazole caplet 40mg for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on September 27, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the prophylaxis. You say that this service was rendered by an OON provider. The Plan also says that the treating provider advised you that they were in-network as of September 17, 2021. You also say that based on this information you thought the service would be covered. The Plan denied your request. The Plan says your coverage only provides for this service when performed by a participating network provider.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided on September 27, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission will help you transition back into the community with independence outcomes that you could not achieve at a lower level of care. The Plan denied your request. The Plan says the criteria for admission to the IRF setting have not been met. Your ongoing skilled therapy and nursing needs can be provided at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the inpatient hospital stay provided by a network facility from September 28, 2021, to October 2, 2021.
You asked the Plan to waive the copayments for the inpatient hospital stay. You say that you are appealing this copayment due to conditions at the hospital. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $300 copayment for each day in an in-network hospital for the first five days.
You have been asked to pay a $300 copayment for each day of the inpatient hospital stay. ($300 x 4 days = $1,200). The inpatient hospital stay falls within "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 copayments for the inpatient hospital stay provided by a network facility from September 28, 2021, to October 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for radiation therapy provided by a network facility from July 20, 2021, to September 23, 2021.
You asked the Plan to waive the copayments for the radiation therapy. You say that you were told by the Plan that the radiation would be 100% covered. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $60 copayment for each Medicare-covered radiation therapy service.
You have been asked to pay a $60 copayment for the radiation therapy on each date of service. ($60 x 30 dates of service = $1,800). The radiation therapy falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" 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 copayments for radiation therapy provided by a network facility from July 20, 2021, to September 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nonpowered advanced pressure reducing overlay for mattress (E0371).
You asked the Plan to pre-approve orthopedic mattress. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the enrollee did not meet the clinical criteria.
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 orthopedic mattress. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found provided records do not document that the enrollee has multiple stage 2 pressure ulcers located on the trunk or pelvis which have failed to improve over the past month during which time the enrollee has been on a comprehensive ulcer treatment program. Records do not document the enrollee has large or multiple stage 3 or 4 pressure ulcer(s) on the trunk or pelvis or has had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days and has been on a group 2 or 3 support surface immediately prior to discharge from a hospital or nursing facility within the past 30 days. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of orthopedic mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve nonpowered advanced pressure reducing overlay for mattress (E0371).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a third level of medial branch blocks.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there was no documentation of unique circumstances for the treatment.
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under certain medical indications.
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 requested services. Our physician reviewer found that the enrollee has chronic low back pain due to lumbar spondylosis and lumbar facet arthropathy. A three or four-level procedure bilaterally may be considered under unique circumstances and with sufficient documentation of medical necessity on appeal. The clinical record provided does not included any documentation that relates and/or substantiates the need for additional injections at multiple levels in the same procedure The review has determined that the enrollee does not have a covered indication for the
requested 3-level bilateral lumbar medial branch blocks as requested.
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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a third level of medial branch blocks.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs received on October 1, 2021, and
October 2, 2021.
You asked the Plan to pay for the drugs. You say that you are unable to afford this payment. The Plan denied
your request. The Plan says the claim processed correctly and in accordance with the Evidence of Coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 pay for self-administered drugs received
on October 1, 2021, and October 2, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the extremity study (93970) provided on July 8, 2021, by an
OON provider.
You asked the Plan to pay for the extremity study. You say that the extremity study (93970) code does not
require prior authorization and the treating provider is in-network with the Plan. The Plan denied your request.
The Plan says both the referring and attending providers are non-participating with the Plan. The Plan also says
that prior authorization was not obtained.
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 extremity study (93970) provided on July 8,
2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve onabotulinumtoxinA (Botox) (CPT code J0585).
You asked the Plan to pre-approve the medication. You say that the medication is for symptoms (urinary frequency and urgency) caused by an enlarged gland (benign prostate hypertrophy). The Plan denied your request. The Plan says that Botox for a member with overactive bladder with urgency, frequency, incontinence as anticholinergic medications were not tried and failed.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 the medication. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found there is documentation that meets the requirements listed in the LCD: Botulinum Toxins (L38809) for Medicare coverage. Botox is indicated for the treatment of overactive bladder with symptoms of urge urinary incontinence, urgency and frequency in patients with an inadequate response to or intolerance of anticholinergic medications. Provided records (office visit note of February 23, 2022) document overactive bladder with detrusor instability on urodynamics with ongoing urgency and frequency symptoms despite active use of anticholinergic medication (solifenacin 10 mg daily). 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 medication have been met. Therefore, we decided that the Plan has to pre-approve onabotulinumtoxinA (Botox) (CPT code J0585).
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 pay for the parathyroid imaging services provided on November 12,
2021, by an OON provider.
You asked the Plan to pay for the parathyroid imaging services. You say that the services were medically
necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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. The
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we
decided that the Plan does not have to pay for the parathyroid imaging services provided on November 12,
2021, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the total electric hospital bed (E0266), provided on September 30, 2021.
You asked the Plan to pay for the total electric hospital bed. You say that the item is medically necessary. The Plan denied your request. The Plan says this is not a covered item.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pay for the total electric hospital bed (E0266), provided on September 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit on September 24, 2021.

You asked the Plan to waive a copayment for a dermatology specialist office visit. You say that the visit was too quick and too abrupt. You also say that the doctor did not examine you. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $45 copayment for a specialist visit.

You have been asked to pay a $45 copayment for a specialist office visit. A specialist 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 a specialist office visit on September 24, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from August 23, 2021, to September 1, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was medically necessary. The Plan denied your request. The Plan says that the inpatient stay was not medically necessary, and the necessary care could have been safely provided in an outpatient observation setting.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the records show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from August 23, 2021, to September 1, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675).
You asked the Plan to pay for a pneumatic compression device. You say that the item is medically necessary.
The Plan denied your request. The Plan says this is not covered for the prevention of deep vein thrombosis
during or after surgery in any setting.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to
pay for a pneumatic compression device (E0675).