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

We decided that the Plan does not have to pay for resin-based composites - two surfaces, anterior (D2331) and
resin-based composite - one surface, posterior (D2391) provided April 28, 2021.
You asked the Plan to pay for the resin-based composite fillings. You say that the charges for the services are
excessive. The Plan denied your request. The Plan says you have exceeded the frequency limit for these
services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers two fillings
per calendar year.
We looked at the file and Medicare rules. The Plan provided documentation showing that coverage was
previously provided for fillings on March 18, 2021, and March 31, 2021. Based on this information, we
decided that the Plan's frequency limit for coverage of the resin-based composite fillings has been exceeded.
Therefore, we decided that the Plan does not have to pay for resin-based composites - two surfaces, anterior
(D2331) and resin-based composite - one surface, posterior (D2391) provided April 28, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for colorectal cancer 
treatment. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says you can be managed 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 
a referral out-of-network for colorectal cancer treatment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom fabricated abutment - includes placement (D6057), abutment supported retainer for porcelain fused to metal fixed partial denture (noble metal) (D6071), and pontic - porcelain fused to noble metal (D6242).
You asked the Plan to pre-approve a custom fabricated abutment, abutment supported retainer and pontic. You say that the services are medically necessary, and you don't understand why it is not covered. The Plan denied your request. The Plan says these services are not covered.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a custom fabricated abutment - includes placement (D6057), abutment supported retainer for porcelain fused to metal fixed partial denture (noble metal) (D6071), and pontic - porcelain fused to noble metal (D6242).
Your complaint about the Plan potentially covering one part of a dental service and not another is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pain injections to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve pain injections. You say that this is the only facility near you. The Plan denied your request. The Plan says there are in-network providers available to provide the medical care you need.
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 pain injections to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on June 17, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the drug testing. You say that the service is 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 service at issue was urgent or emergent.
Therefore, we decided that the Plan does not have to pay for the drug testing provided on June 17, 2020 by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided on June 3, 2021.
You asked the Plan to pay for psychotherapy, 30 minutes with patient (90832). You say that the Plan should pay this claim. The Plan denied your request. The Plan says there was no documented contact with the attending /primary care physician.
The Plan must follow Medicare rules. Medicare rules say that there must attempt to consult the attending or primary care physician about the services furnished and document the consent or declination date to consultations, and the date of consultations in the patient's medical record. We looked at the file and Medicare rules. There is no documentation of consent/declination or consultation with the enrollee's attending or primary care physician. Based on this information, we decided that Medicare rules for coverage of psychotherapy, 30 minutes with patient (90832) have not been met. Therefore, we decided that the Plan does not have to pay for psychotherapy provided on June 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for LTACH care have not been met because the requested level of care is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that the enrollee is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve the LTACH services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a fine needle aspiration biopsy provided on March 9, 2021.
You asked the Plan to waive the copayment for a fine needle aspiration biopsy. You say that you arrived to the appointment and the physician said that you did not need a biopsy. 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 $350 copayment for outpatient surgery, including services provided at hospital outpatient facilities. The record shows that you received a fine needle aspiration biopsy on March 9, 2021. A fine needle aspiration biopsy is considered an outpatient surgical procedure. Therefore, you are responsible to pay $162.30, which is less than the $350 copayment.
You have been asked to pay $162.30 for a fine needle aspiration biopsy. A fine needle aspiration biopsy falls 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
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane (J7318).
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 that this appeal considers the request for Durolane in a 63-year-old female for the treatment of primary osteoarthritis of bilateral knees. The enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires that 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. Without the support of the documentation, Durolane is not approved as step criteria have not been met. 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 (J7318
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 the requested admission to an IRF is medically necessary. 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 the enrollee does 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 the enrollee 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 an inpatient hospital stay and a SNF stay
provided from February 24, 2021, to March 23, 2021.
You asked the Plan to waive the copayments for an inpatient hospital stay and a SNF stay. You say that you
disagree with the charges and should not owe anything. The Plan denied your request. The Plan says the claims
were processed correctly, and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325
copayment for days 1-5 for inpatient hospital care. Your contract with the Plan also clearly says that you must
pay a $0 copayment for days 1-20 and a $184 copayment for days 21-100 for SNF care.
You had an inpatient hospital stay from February 24, 2021, to March 2, 2021. Therefore, you are responsible to
pay a $325 copayment for days 1-5 (February 24, 2021, to February 28, 2021). The total amount you owe is
$325 (copayment) x 5 (inpatient days) = $1,625.
You had a SNF stay from March 2, 2021, to March 23, 2021. You are not being charged a copayment for days
1-20 (March 2, 2021, to March 21, 2021). You are responsible to pay a $184 copayment for day 21 (March 22,
2021).
The total amount you owe is: $1,809.
You have been asked to pay the total copayment amount of $1,809 for an inpatient hospital stay and a SNF
stay. An inpatient hospital stay falls within the inpatient hospital care benefit category. A SNF stay falls within
the SNF 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 an inpatient hospital stay
and a SNF stay provided from February 24, 2021, to March 23, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) services 
 
You asked the Plan to pre-approve SNF services. You say that the member needs skilled nursing and rehab for 
essential tremor, assistance with eating, activities of daily living, increasing safety and to improve nutrition. 
The Plan denied your request. The Plan says the stay is not medically necessary. 

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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found no evidence that you have the degree of 
disability or medical complication following a hospitalization related to weight loss and a tremor of the hands 
that would require rehabilitation in an inpatient skilled nursing facility. Our reviewer says that you do not have 
daily skilled needs or other medical needs that require the skills of a licensed professional in an inpatient 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the SNF services.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay more for the ocular prosthesis you received from a non-contracted durable
medical equipment/prosthetic provider on March 4, 2021.
You asked the Plan to pay more for the ocular prosthesis. You say that you were told that you would be
reimbursed 80% of the cost of the prosthesis, which is $2400. The Plan denied your request. The Plan says that
it has reimbursed you the Medicare-allowed rate ($942.94) minus your coinsurance obligation ($188.59),
which equals $754.35. The Plan claims that you signed a document with the provider stating that you would be
responsible for the difference between what you paid and the Medicare allowable rate.
The rules say that when you get durable medical equipment (DME)/prosthetics from a non-contracted DME
vendor that doesn't participate with Medicare, the Plan is responsible for the difference between your cost
sharing and the supplier's bill. That is the case here. This supplier is not a contracted provider with the Plan.
On the letter that the Plan sent you dated August 23, 2021, they have confirmed that this supplier does not
participate in Medicare. The fact that you may have signed something agreeing to pay more does not negate
the Plan's obligation to follow Medicare rules. Medicare rules clearly state that the Plan, not you, is
responsible for the difference between the $3000 invoice and your 20% coinsurance (which, based on the
invoice amount, would be $600.) The Plan cannot bypass this Medicare rule simply because you may have
signed a document with the provider.
This means that the Plan did not follow Medicare rules for regarding balance billing for DME/Prosthetics.
Therefore, we decided that the Plan has to pay more for the ocular prosthesis you received from a noncontracted
durable medical equipment/prosthetic provider on March 4, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the lower partial denture provided (D5212) on June 18, 2021.
You asked the Plan to pre-approve the lower partial denture provided (D5212). You say that you deserve to use any benefits and are appealing the denial of payment for your dentures. The Plan denied your request. The Plan says reimbursement was already issued for a lower partial denture.
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, you also have a maximum benefit of one lower partial denture every five years. The Plan paid for the lower partial denture provided on April 5, 2019, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the lower partial denture provided (D5212) on June 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve levothyroxine, 50 mcg capsule.
You asked the Plan to pre-approve levothyroxine. You say that the enrollee has been stable on this medication
since June 2021. The Plan denied your request. The Plan says the requested drug is considered selfadministered.
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 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 pre-approve levothyroxine, 50 mcg
capsule.
Benefits for levothyroxine may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a practitioner visit provided on May 12, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for practitioner visit. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and 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 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 a practitioner visit provided on May 12, 2021 by an out-of-network (OON) provider.