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

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and waive the
out of network cost sharing for the prophylaxis (D1110) provided on October 12, 2021 by the out of network
provider.
You asked the Plan to pay for the dental services. You say that you did not like the first dentist you saw. You
also say that this should be covered. The Plan denied your request. The Plan says 1 comprehensive oral
evaluation is covered every 3 plan years. The Plan says that the frequency limit has been exceeded. The Plan
also says that out of network providers may bill you for any amount greater than what the Plan pays.
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 comprehensive oral evaluation is
listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a
comprehensive oral evaluation that you received on February 9, 2021. Additionally, out of network providers
may bill you for any amount greater than what the plan pays. Therefore, we decided that the Plan does not have
to pay for the comprehensive oral evaluation (D0150) and waive the out of network cost sharing for the
prophylaxis (D1110) provided on October 12, 2021 by the out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient level of care admission for a right total hip arthroplasty (27130).

You asked the Plan to pre-approve the inpatient level of care admission. You say that your doctor feels it is necessary for you to be admitted to the inpatient level of care based on your medical history. The Plan denied your request. The Plan says that for this procedure to be approved at an inpatient level of care, complicated medical conditions should be present. The Plan also says that the information provided does not show you have complicated medical conditions.

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 pre-approve the inpatient level of care admission. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee has a history of coronary artery disease status post Myocardial infarction (MI) twice. You are medically stable without any uncontrolled underlying medical conditions that make you high risk for complications and observation status appears to be medically necessary. Our reviewer found that there is no clinical rationale for inpatient level of care services. Our physician reviewer also found that the record does not show that the admitting physician reasonably expects that your necessary hospital 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 the inpatient level of care admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient level of care admission for a right total hip arthroplasty (27130).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus Gene Panel provided on August 24, 2021.
You asked the Plan to pay for the testing.
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 pay for the testing. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that there is no specific clinical rationale for the requested test. The medical records received do not
show the above criteria which are necessary for approval. The review has determined that the genetic testing in
this case is not medically reasonable or necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have
to pay for the Tempus Gene Panel provided on August 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for several durable medical equipment items ordered from
Amazon.com or other out-of-network providers from October 20, 2020, to November 19, 2020.
You asked the Plan to pay for these items. You say that you were told these items would be covered by the
Plan. The Plan denied your request.
The Plan says the retails providers used are not Medicare eligible durable medical equipment providers. You
did not have prior authorization for out of network durable medical equipment.
Medicare does not pay for items or services from providers who are not eligible to accept Medicare payment.
Medicare rules say that plans can require enrollees to get care from network providers. The Plan contract says
that enrollees must use in network providers who are Medicare eligible providers. The contract with the Plan
says that durable medical equipment may require prior authorization.
You ordered this equipment without prior authorization from a retail commercial provider who is both out of
network and is not a Medicare eligible provider. You did not follow your Plan contract rules when you
purchased this equipment. Therefore, we decided that the Plan does not have to pay for several durable medical
equipment items ordered from Amazon.com or other out-of-network providers from October 20, 2020, to
November 19, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics.
You asked the Plan to pay for foot orthotics. You say that the item is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Coronavirus testing rendered on September 1, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says only one Coronavirus test is covered per day.
The Plan must follow Medicare rules. Medicare rules say that all ESRD-related laboratory services are included in the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. The Plan states that only one COVID-19/Coronavirus test is covered per day. We looked at the file and Medicare rules. The file shows that the Coronavirus testing was billed with diagnosis code N18.6 for end-stage renal disease (ESRD). Under Medicare rules, payment for these services is included in the ESRD payment. However, the Plan covers one Coronavirus test per day. One test was paid. The second test is not covered per the Plan rules. Therefore, we decided that the Plan does not have to pay for the Coronavirus testing rendered on September 1, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy (EGD) (43235).
You asked the Plan to pre-approve the EGD. You say that the enrollee needs to have an upper/lower endoscopy
to medically determine what is going on with her. You also say that the enrollee has never had an upper
endoscopy. The Plan denied your request. The Plan says that an upper endoscopy is not medically necessary at
this time because the documentation received fails to indicate the enrollee meets the criteria.
The Plan follows Medicare rules. Medicare rules say that indications which support
esophagogastroduodenoscopies (EGD[s]) for diagnostic purpose(s) include the presence of gastrointestinal
bleeding for presumed chronic blood loss and for iron deficiency anemia when colonoscopy is negative.
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 EGD. Our reviewer says that the
EGD does not meet coverage criteria. Our physician reviewer found the record indicates that the enrollee has
iron deficiency anemia. Our reviewer found that the enrollee in this case has not yet had a negative
colonoscopy for this issue. Our physician reviewer also found that the elements of the coverage rules are not
satisfied, and the requested service cannot be recommended.
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 EGD have not been met. Therefore, we decided that the Plan does not have
to pre-approve an esophagogastroduodenoscopy (EGD) (43235).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for X-ray examinations of the chest (71045), of the hip (73502),
of the femur (73552), and of the knee (73564) provided on March 16, 2021.
You asked the Plan to pay for X-ray examinations. You say that the services at issue were a medical necessity
for the enrollee. The Plan denied your request. The Plan says the provided records do not support the services
billed.
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 71045 is "Radiologic examination, chest; single view";
the definition of code 73502 is "Radiologic examination, hip, unilateral, with pelvis when performed; 2-3
views"; the definition of code 73552 is "Radiologic examination, femur; minimum 2 views"; and the definition
of code 73564 is "Radiologic examination, knee; complete, 4 or more views."
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 X-ray examinations. Our reviewer says that the CPT codes at
issue do not meet criteria for billing or reimbursement consideration. Our reviewer found that the medical
records provided do not include sufficient documentation to validate that the X-ray examinations at issue were
performed on March 16, 2021. Therefore, these procedures cannot be verified.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of X-ray examinations have not been met. Therefore, we decided that the Plan
does not have to pay for X-ray examinations of the chest (71045), of the hip (73502), of the femur (73552), and
of the knee (73564) provided on March 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Oxycodone-Acetaminophen tablet.
You asked the Plan to pre-approve Oxycodone-Acetaminophen. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Oxycodone-Acetaminophen tablet.
Benefits for Oxycodone-Acetaminophen 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 the Humira Pen.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under 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 the Humira Pen.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), prophylaxis (D1110) and bitewing images (D0274) provided on August 19, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for a comprehensive oral evaluation, prophylaxis and bitewing images. You say that you thought you would be covered with your Plan. You also say you would like to be reimbursed for these services. The Plan denied your request. The Plan says services performed by an OON provider are not covered because your healthcare plan does not have OON benefits.

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 a comprehensive oral evaluation, prophylaxis and bitewing images when you receive services from an in-network provider.

We looked at the file and Medicare rules. Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for 100% of the cost for dental services rendered by an OON provider. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation, prophylaxis and bitewing images have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), prophylaxis (D1110) and bitewing images (D0274) provided on August 19, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from April 4, 2021, to April 9, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you developed pneumonia from your surgery and you do not feel responsible for the hospital copayment for this reason. 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 $200 per day for days 1-5 and $0 per day after day 5 for each inpatient benefit period.
The file shows that you were in the hospital from April 4, 2021, to April 9, 2021. Therefore, you have been asked to pay $200 per day for the first 5 days of inpatient hospital services. The total for your stay is $1000 ($200 copayment x 5 days = $1000). The inpatient hospital services fall within the 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 copayment for inpatient hospital services provided from April 4, 2021, to April 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Savaysa 60 mg tablet.
You asked the Plan to pre-approve Savaysa. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.
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 Savaysa 60 mg tablet.
Benefits for Savaysa 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 pre-approve an epidural steroid injection.
You asked the Plan to pre-approve epidural steroid injection. You say that the enrollee continues to report pain
and would benefit from epidural steroid injection. The Plan denied your request. The Plan says the denial of
authorization for this service is correct, because the records do not show that the previous shot provided 50%
pain relief for 3 months, that the enrollee's pain did not get better with medication, or that physical therapy did
not help.
The Plan follows Medicare rules. Medicare rules state that repeat epidural steroid injection may be covered if
the initial epidural steroid injection provided 50% pain relief for 3 months.
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 epidural steroid injection. Our reviewer
says that the enrollee does not meet the Medicare criteria for the requested epidural. Our physician reviewer
found the records do not show that the previous epidural injection provided 50% pain relief for 3 months. The
previous epidural provided pain relief for only 3 weeks.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of epidural steroid injection have not been met. Therefore, we decided that the
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan state the
enrollee could receive care in another setting and the plan could review alternate settings if requested such as a
skilled nursing facility, outpatient setting or home health 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for bacteremia, urinary tract infection, and atrial fibrillation with rapid ventricular response.
Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an
intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational
therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable
expectation that this patient 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 IRF admission and services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the room and board charges provided from May 22, 2021, to
May 31, 2021.
You asked the Plan to pay for the room and board charges. You say that you would like this claim to be
reprocessed. The Plan denied your request. The Plan says the enrollee elected hospice on May 22, 2021, to July
20, 2021. The Plan also says that the services submitted is within the hospice election period, and the claim is
the financial responsibility of Medicare fee-for-service.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the room and board charges provided from May 22, 2021, to
May 31, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya (J3245).
You asked the Plan to pre-approve Ilumya. The Plan denied your request. The Plan says this request does not
meet the Plan's Part B step therapy criteria for Ilumya.
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 Ilumya. Our reviewer says that Ilumya
(J3245) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the enrollee
has not tried and failed the required drugs, Remicade, Inflectra, or Infliximab and Stelara. Our reviewer also
found that there is no indication that the Plan's required drugs would likely be less effective and/or likely have
adverse effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to
pre-approve Ilumya (J3245).