Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Prolia (J0897).

You asked the Plan to pre-approve Prolia. You say that the requested drug is a medical necessity for you. The Plan denied your request. The Plan says step therapy rules for the requested drug 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 Prolia. Our reviewer says that the requested treatment is not medically and reasonable in this case. Our physician reviewer found that the Plan requires a trial of drugs Reclast and Fosamax before they will approve the requested drug, Prolia. Based on the medical records provided, you have not tried and failed the required drugs. Based on the medical records provided, there is the risk of adverse effects with Fosamax therapy due to a history of gastroesophageal reflux disease, but records do not document that treatment with intravenous Reclast would likely be less effective and/or likely have adverse effects for you. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Prolia (J0897).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pontics and retainer crowns for a fixed bridge.

You asked the Plan to pre-approve the pontics and retainer crowns. The Plan denied your request. The Plan says you do not meet the criteria for coverage of a bridge.

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 the pontics and retainer crowns when the services are medically necessary and reasonable. 

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 pontics and retainer crowns. Our physician reviewer found that there are four missing posterior teeth and there are no front teeth being replaced. Our reviewer says that the periodontal condition of the potential abutment teeth is severely compromised, with 50% or less bone remaining on #32 and #29. Our reviewer says that given the Plan limitations, there is no medical necessity for the requested bridge.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the pontics and retainer crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve the pontics and retainer crowns for a fixed bridge.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement hospital bed mattress.
You asked the Plan to pre-approve the hospital bed mattress. You say that the mattress is very old and has
springs coming through from the box spring. The Plan denied your request. The Plan says there is no evidence
that the mattress needs to be replaced.
The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary
when at least one of the following criteria is met:
1. The patient has a medical condition which requires positioning of the body in ways not feasible with an
ordinary bed; or
2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate
pain; or
3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to
congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have
been considered and ruled out; or 4. The patient requires traction equipment, which can only be attached to a hospital bed. A hospital bed mattress can only be covered when the hospital bed itself is covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the hospital bed mattress. Our reviewer says that the documentation does not support that Medicare criteria for the hospital bed are met. Our physician reviewer found the enrollee has limited mobility due to neuropathy. There is no specific clinical rationale for a hospital bed. The review has determined that the requested hospital bed is not medically necessary for this patient. 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 hospital bed mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement hospital bed mattress.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) and the destruction of premalignant lesions (17000) rendered by the out-of-network (OON) provider on June 15, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.

We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the office visit (99203) and the destruction of premalignant lesions (17000) rendered by the out-of-network (OON) provider on June 15, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to waive the coinsurance for the revision of a total knee arthroplasty provided on 
April 21, 2021. 
 
You asked the Plan to waive the coinsurance for the revision of a total knee arthroplasty. You say that the 
enrollee did not receive self-administered drugs and you disagree with the charges. The Plan denied your 
request. The Plan says that the claims were processed correctly and the enrollee is 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). The Plan contract does not say in clear and accurate terms how 
much enrollees should expect to pay for outpatient surgery and other medical services provided at hospital 
outpatient facilities and ambulatory surgical centers.  
 
The Plan contract does not break down when a $0 copayment applies or when 20% coinsurance applies for 
outpatient surgery services. Therefore, the contract is ambiguous.  
 
We looked at the contract between the enrollee and the Plan. We did not see where the contract says when 
enrollees must pay 20% coinsurance for outpatient surgery and other medical services provided at hospital 
outpatient facilities and ambulatory surgical centers. The Plan contract does not clearly say how much enrollees 
must pay for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers. This means that the Plan did not follow Medicare rules for disclosure of cost 
sharing information. Therefore, we decided that the Plan has to waive the coinsurance for the revision of a total 
knee arthroplasty provided on April 21, 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 pre-approve a raised toilet seat.

You asked the Plan to pre-approve a raised toilet seat. You say that you have a prosthetic hip and cannot bend. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature. While a raised toilet seat may be appropriate for L. 

White, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider on April 23, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider on
April 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the x-ray of the foot you had on June 3, 2021.

You asked the Plan to reduce the copayment for the x-ray. You say that this service should only have a $45 copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $60 copayment for x-rays. 

You have been asked to pay a $60 copayment for the x-ray. 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 reduce the copayment for the x-ray of the foot you had on June 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine to be rendered by the out-of-network (OON) provider.
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.
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 service at issue in this appeal.
We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine to be rendered by the out-of-network (OON) provider
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound services coded as 76519 provided on May 5,
2021.

You asked the Plan to pay for the ultrasound services. You say that the medical records support the code as
billed. The Plan denied your request. The Plan says the medical records do not corroborate the services
provided.

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 76519 is ophthalmic biometry by ultrasound echography,
A-scan; with intraocular lens power calculation.

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 the ultrasound services. Our reviewer says that the medical
records do not support the code as billed. Our reviewer found the medical records provided do not include
sufficient documentation to validate that an ophthalmic biometry by ultrasound echography, A-scan; with
intraocular lens power calculation was performed on May 5, 2021. As a result, this service cannot be verified
with the documentation provided.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the ultrasound services have not been met. Therefore, we decided that the Plan
does not have to pay for the ultrasound services coded as 76519 provided on May 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the podiatry visit you had on July 19, 2021. 
 
You asked the Plan to waive the copayment for the podiatry visit. You requested reimbursement of this 
copayment but you did not provide an explanation as to why in your appeal request. The Plan denied your 
request. The Plan says you were charged this copayment 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 $25 
copayment for podiatry services.  
 
You have been asked to pay a $25 copayment for the podiatry visit. 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 podiatry visit you had on July 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound study provided on May 4, 2021.
You asked the Plan to waive the copayment for an ultrasound study. You say that you should only owe a $30 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 a $125 copayment for ultrasounds. You have been asked to pay the allowed amount of $83.22, which is less than the $125 copayment an ultrasound study. An ultrasound study 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 copayment for an ultrasound study provided on May 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy (PT) visit you had at 
an outpatient hospital on June 18, 2021. 
 
You asked the Plan to waive the copayment for the PT visit. You say that you have Medicaid so you don't think 
you owe this amount. you say that you cannot afford this copayment. The Plan denied your request. The Plan 
says you were charged this copayment correctly.  The Plan says you can have the provider submit the claim to 
Medicaid. 
 
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 $30 
copayment for physical therapy at an outpatient hospital.  
 
You have been asked to pay a $30 copayment for the PT visit. 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 physical therapy (PT) visit you had at an outpatient hospital on June 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that the requested item is needed 
allow you to move about freely and travel. The Plan denied your request. The Plan says rules for oxygen 
equipment have not been met. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a regular oxygen concentrator. Your regular oxygen concentrator serves the same 
medical purpose as the requested portable oxygen concentrator. Therefore, we decided that the Plan does not 
have to pre-approve a portable oxygen concentrator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services provided on June 2, 2021.

You asked the Plan to pay for the services provided. You say that the code is a separate and billable procedure. The Plan denied your request. The Plan says the rules for payment have not been met.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. 

In this case, the MUE for CPT code 99291 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services provided on June 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit you had with a chiropractor on January 14, 
2021. 
 
You asked the Plan to pay for the chiropractic office visit. You say that you had a physical with your primary 
care provider who referred you to a chiropractor for hip pain.  You said that it was determined that you needed 
hip resurfacing. The Plan denied your request. The Plan says routine chiropractic office visits are not a covered 
benefit.  The Plan says that the only chiropractic service that is covered is manual manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit you had with a chiropractor on January 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network 
(OON) provider on June 8, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.

We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on June 8, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve seven additional resin-based composites. 
 
You asked the Plan to pre-approve the additional resin-based composites. You say that right now you can only 
eat soft foods and cannot afford to pay for the fillings or cleaning. You say that you need the fillings and 
cleaning in order to get your partial dentures. The Plan denied your request. The Plan says your benefits have 
been exhausted for the 2021 plan year. 
 
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 maximum benefit of 
four amalgam or resin-based composite fillings per calendar year. The Plan approved four resin-based 
composites for tooth #'s 21-24 on July 16, 2021, which exhausted your benefits. Therefore, we decided that the 
Plan does not have to pre-approve seven additional resin-based composites.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on June 18, 2021, 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 18, 2021, by an out-of-network (OON) provider.