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

We decided that the Plan does not have to pay for the unspecified periodontal procedure (D4999), periodontal maintenance (D4910), the unspecified preventive procedure (D1999), topical application of fluoride varnish (D1206), the initial periapical x-ray (D0220), and 3 additional periapical x-rays (D0230) provided on April 14, 2021.
You asked the Plan to pay for the dental services. You say that you have been seeing this provider for years. You say that this provider has always been in network. You also say that had you known that this provider was out of network, you would have postponed your dental work. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for dental services performed by a provider that has opted out of Medicare.
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, dental services performed by a provider who has opted out of Medicare are not eligible for payment. Therefore, we decided that the Plan does not have to pay for the unspecified periodontal procedure (D4999), periodontal maintenance (D4910), the unspecified preventive procedure (D1999), topical application of fluoride varnish (D1206), the initial periapical x-ray (D0220), and 3 additional periapical x-rays (D0230) provided on April 14, 2021.
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 you will need intensive physical therapy for safety reasons and significant progress and recovery. You also say you need the rehab for tools and exercises to get you back functioning normally and safely at home. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 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: Favorable

We decided that the Plan has to pre-approve an inpatient hospital admission.
You asked the Plan to pre-approve the inpatient hospital admission. You say that you were sick and were hospitalized, and do not feel you should owe the payment. The Plan denied your request. The Plan says that your request is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. We looked at the file and Medicare rules. Based on this information we have decided that the Plan has to pre-approve the inpatient hospital admission. The record clearly indicates that the Plan reviewed clinical information. Of note, we requested this clinical information, and none was received. It is the burden of the Health Plan to substantiate their denial with evidence. This denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pre-approve an inpatient hospital admission.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia injection.

You asked the Plan to pre-approve denosumab, 1 mg (J0897). You say that the enrollee has contraindications to bisphosphonates. The Plan denied your request. The Plan says the enrollee has not tried and failed an oral bisphosphonate and zoledronic acid.

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 denosumab, 1 mg (J0897). Our
reviewer says that the drug is not medically reasonable and necessary. Our physician reviewer found based on
the medical records provided the patient has not tried and failed the required drug(s). There is no indication that
zoledronic acid would likely be less effective and/or likely have adverse effects for the patient. The prescriber
has argued that intravenous zoledronic acid is contraindicated due to a creatinine clearance of 50 mL/minute.
As summarized in Drugdex/Micromedex and The American Hospital Formulary Service-Drug Information, no
zoledronic acid dosage adjustment is required for a creatinine clearance of 35 mL/minute or greater.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of denosumab, 1 mg (J0897) have not been met. Therefore, we decided that the
Plan does not have to pre-approve Prolia injection.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve orthopedic surgery services to be provided by an out-ofnetwork
(OON) provider.
You asked the Plan to pre-approve OON services. You say that you are in pain and your mobility is limited.
The Plan denied your request. The Plan says services can be provided 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 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 services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve
orthopedic surgery services to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that you are a fall risk if you are home alone. The Plan
denied your request. The Plan says your needs can be met at a lower level of care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the records show that you do not have skilled
nursing needs. While you need skilled therapy services, you do not need them on a daily basis. You do not
meet the severity of illness or intensity of service criteria for inpatient care in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a laminectomy for the implantation of neurostimulator electrodes provided on May 27, 2021.
You asked the Plan to waive the copayment for a laminectomy for the implantation of neurostimulator electrodes. You say that the electrodes were not able to be placed during the surgery and you request that your copayment be waived. 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 $400 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.
The medical records show that you received a laminectomy for the implantation of neurostimulator electrodes on May 27, 2021. A laminectomy for the implantation of neurostimulator electrodes is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $400 copayment. You have been asked to pay a $400 copayment for a laminectomy for the implantation of neurostimulator electrodes. A laminectomy for the implantation of neurostimulator electrodes fall within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 laminectomy for the implantation of neurostimulator electrodes provided on May 27, 2021.
We note your complaint that the implantation of neurostimulator was not performed. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a standing frame/table system (E0641).
You asked the Plan to pre-approve a standing frame/table system. You say that the item is medically necessary.
The Plan denied your request. The Plan says the requested item is considered an item of comfort or
convenience and not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve a standing frame/table system (E0641).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on May 19, 2021, and June 16, 2021.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you were quoted as only owing a $310 copayment. 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 Medicare Part B drugs on May 19, 2021. The total allowed amount is $2,507.81 and 20% of that is $501.56. You received Medicare Part B drugs on June 16, 2021. The total allowed amount is $1,880.85 and 20% of that is $376.17. The total amount you owe is: $877.73. You have been asked to pay the total coinsurance amount of $877.73 for Medicare Part B drugs. Medicare Part B drugs fall 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 Medicare Part B drugs provided on May 19, 2021, and June 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periapical x-rays (D0230 x 2) provided on June 10, 2021.
You asked the Plan to pay for the dental services. You say that you verified with the plan that you were
covered. You say that you told the dentist you can only afford 1 x-ray. You also say that now you owe $64. The
Plan denied your request. The Plan says 1 periapical x-ray is 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 and periapical x-ray is listed as
covered, the frequency limit has been exceeded. The record shows that the Plan paid for a periapical x-ray that
you received on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the
periapical x-rays (D0230 x 2) provided on June 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a hearing aid received on March 31, 2021.
You asked the Plan to reimburse you for a hearing aid. You say that you lost your hearing aid, then when you found it you wanted to return it for a refund as you felt it did not fit properly. The Plan denied your request. The Plan says costs associated with loss and damage are not covered by the Plan.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of a hearing aid have not been met. Specifically, the Plan does not cover costs for hearing aids associated with loss and damage. Therefore, we decided that the Plan does not have to reimburse you for a hearing aid received on March 31, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95870) and short latency somatosensory testing (95938) provided on July 1, 2020.
You asked the Plan to pay for the needle electromyography and short latency somatosensory testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT codes 95870 and 95938 do not meet the diagnosis code relationship criteria.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 95870 and 95938 are not supported in the medical record. CPT codes 95870 and 95938 have specific diagnosis codes for billing. The diagnosis codes billed on this claim are not included in the list of appropriate codes for CPT codes 95870 and 95938. Based on this information, we decided that Medicare rules for coverage of the needle electromyography and short latency somatosensory testing have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography (95870) and short latency somatosensory testing (95938) provided on July 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive audiometry evaluation (92557) audiologic function tests (92567) provided on April 23, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the audiology services. You say that you had called beforehand and was told by a Plan representative that the provider is participating. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 comprehensive audiometry evaluation (92557) audiologic function tests (92567) provided on April 23, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar sacral orthosis, knee orthoses and sleeves provided to the enrollee on October 16, 2020.
You asked the Plan to pay for these items. You say that you provided services based on the prescription and notes you received from the doctor. The Plan denied your request. The Plan says that documentation indicates services are not necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.
We looked at the file and Medicare rules. The Plan states that these items may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of these items have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar sacral orthosis, knee orthoses and sleeves provided to the enrollee on October 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Guardant360 testing.

You asked the Plan to pre-approve Guardant360 testing. You say that this testing helps your physician find the
best type of treatment for you. The Plan denied your request. The Plan says the denial of authorization for this
testing is correct, because you previously had the same test for the same cancer diagnosis on November 15,
2019.

The Plan must follow Medicare rules. Medicare rules say that next-generation sequencing may be covered
under certain conditions, including that the enrollee has not been previously tested with the same test using
next-generation sequencing for the same cancer genetic content.

We looked at the file and Medicare rules. You were previously tested using the same test for the same cancer
genetic content. Based on this information, we decided that Medicare rules for coverage of Guardant360 testing
have not been met. Therefore, we decided that the Plan does not have to pre-approve Guardant360 testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided to the enrollee on May 17, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says there was no authorization for these services.
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 skilled nursing services provided to the enrollee on May 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1851) and suspension sleeve (L2397)
provided August 9, 2019.
You asked the Plan to pay for the orthoses. You say that previously medical records and related documents for
review were mailed on 11/14/2019. You are located in New York City and serve the patients in the New York
State metropolitan area which is highly affected by Coronavirus. The Plan denied your request. The Plan says
the documentation indicates services are not necessary for treatment of the enrollee's condition. All information
was provided over the phone. There are no clinical notes from the enrollee's primary health provider and no
documented attempts to contact the enrollee's local physician.
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone
regarding the furnishing of a covered item except under specific circumstances.
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an
unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the
enrollee's treating physician. The record does not show that written permission was obtained to make contact
by telephone regarding the furnishing of this item. The record does not show that contact was initiated
regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the
past 15 months. Based on this information, we decided that Medicare rules for coverage of the orthoses have
not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1851) and
suspension sleeve (L2397) provided August 9, 2019