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

We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on February 5,
2021.
You asked the Plan to pay for the evaluation and management service. You say that the claim should be
reprocessed and paid. The Plan denied your request. The Plan says the enrollee's claim would be covered under
Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the
last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify
the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare
Advantage member on hospice.
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 subsequent hospital care (99232) provided on February 5,
2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home ventilator (E0466) provided on August 30, 2021.  You asked the Plan to pay for the durable medical equipment. You say that the enrollee was not enrolled in hospice on the date of service. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  The enrollee ended Medicare Hospice benefits on August 26, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the home ventilator (E0466) provided on August 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3.
You asked the Plan to pre-approve Gelsyn-3. You say that the requested Gelsyn-3 is medically necessary. The
Plan denied your request. The Plan says the enrollee must try and fail Orthovisc or Supartz FX first.
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 Gelsyn-3. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found based on the medical records provided there is no indication that the enrollee has tried and failed the required drug(s). There is no indication that the Plan's required drug(s) 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 Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have to pre-approve Gelsyn-3.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a computed tomography (CT) provided on September 9, 2021.  You asked the Plan to waive the coinsurance for a CT scan. You say that you were told you should not have received a bill from the provider. 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 20% coinsurance for in-network radiological diagnostic services, including CT scans, when performed in a hospital.    You have been asked to pay $70.56, which is 20% of the allowed amount for a CT scan ($352.81 allowed amount x 20% = $70.56). A CT scan falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. Please note that although your provider was out of network, the Plan has processed your claim at the in-network rate. 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 a CT scan provided on September 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Periodic comprehensive preventive medicine reevaluation and management (99397) provided on July 23, 2021.  You asked the Plan to pay for code 99397. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 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.  We looked at the file and Medicare rules. Procedure code 99397 has a status code of "N" under the Medicare Physicians Fee Schedule Database (MPFSDB) and is a non-covered service per Medicare guidelines.  Therefore, we decided that the Plan does not have to pay for the Periodic comprehensive preventive medicine reevaluation and management (99397) provided on July 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the oral exam (D0120), prophylaxis (D1110),
fluoride varnish (D1206), complete series x-ray (D0210), filling (D2391) for tooth # 31, and filling (D2330) for
tooth # 10 provided on April 26, 2021.
You asked the Plan to reimburse you for the dental services. You say that you were not aware that the provider
needed to be enrollee in Medicare in order to eligible for reimbursement. 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 services performed by providers that have 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 that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided
that the Plan does not have to reimburse you for the oral exam (D0120), prophylaxis (D1110), fluoride varnish
(D1206), complete series x-ray (D0210), filling (D2391) for tooth # 31, and filling (D2330) for tooth # 10
provided on April 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Brilinta 90 mg tablet.  You asked the Plan to pre-approve Brilinta. 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 Brilinta 90 mg tablet.   Benefits for Brilinta 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pain management services (62320) provided on October 25, 2021.  You asked the Plan to pay for code 62320. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the records are insufficient to support payment for these services.  The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain documentation requirements must be met. The documentation must include the legible signature of the physician or non-physician practitioner responsible for providing the care to the patient. In addition, the procedure report should clearly document the indications and the medical necessity for the blocks along with the pre and post percent pain relief achieved immediately post-injection.   The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record is not signed and there is no notation of the percent of pain relief achieved either before or after the injection.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay for the pain management services (62320) provided on October 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve crowns (D2740) for teeth # 29 and 31.  You asked the Plan to pre-approve the dental services. You say that the crowns are medically necessary. The Plan denied your request. The Plan says the criteria for the crowns have not been met.  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 dental services 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 dental services. Our reviewer says that the crowns for teeth # 29 and 31 are not medically necessary. Our physician reviewer found the provided documentation shows that the root canal fillings done on these teeth are inadequately filled. Therefore, the reviewer found that the crowns for teeth # 29 and 31 cannot be approved.  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 dental services have not been met. Specifically, the file shows that the root canal fillings are inadequate. Therefore, we decided that the Plan does not have to pre-approve crowns (D2740) for teeth # 29 and 31.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve GenVisc.  You asked the Plan to pre-approve GenVisc. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says 6 months have not elapsed since the previous injection.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve GenVisc. Our reviewer says that the requested GenVisc injections are not medically necessary. Our physician reviewer found the provided records indicate it has been less than six months since completion of the enrollee's prior series of injections. Therefore, the reviewer found that the requested injections are not medically 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 GenVisc have not been met. Specifically, the file shows that it has been less than 6 months since the enrollee's last series of injections. Therefore, we decided that the Plan does not have to pre-approve GenVisc.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on October 26, 2021.  You asked the Plan to pay for the problem focused limited oral evaluation. You say that you saw a dark spot on your tongue that was not present at your previous exam. You also say that you made an appointment with your provider to have the spot examined. The Plan denied your request. The Plan says you were not eligible for an additional oral examination on this date of service.  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 are limited to one oral examination per calendar year. The record shows that you received an oral exam on September 7, 2021 and your oral examination benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on October 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Botox injections.  You asked the Plan to pre-approve Botox injections. You say that the requested Botox injections are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested Botox injections.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Botox injections. Our reviewer says that the enrollee does not meet criteria for the requested Botox injections. Our physician reviewer found based on the medical records provided and the Medicare-approved major drug compendia there is no documentation that Botox injections every 10 weeks meets the above Local Coverage Determination (LCD): Botulinum Toxins (L33646) criteria for the requested Botox injections. The usual retreatment with Botox for migraine is every 12 weeks. As stated in the LCD, the dose and frequency of Botox should be in accordance with the FDA label.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral exam (D0140) provided on September 10, 
2021.
You asked the Plan to pay for the limited oral exam. You say that you wanted a second opinion, and you feel 
this provider should be paid because they gave you the best information and helped resolve your problem. The 
Plan denied your request. The Plan says you had a previous limited oral exam provided on August 26, 2021, 
which was covered by the Plan. Your dental benefit covers only one limited oral exam per 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. The Plan can cover one 
limited exam to evaluate a problem (D0140) per plan year.
Though the Plan offers a dental benefit in excess of Medicare coverage, the limited exam is requested in a 
frequency that exceeds what is covered under this benefit. Documentation shows you had a previous limited
exam in 2021 which was covered by the Plan. Therefore, we decided that the Plan does not have to pay for the 
limited oral exam (D0140) provided on September 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve total knee arthroplasty for the enrollee.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says currently there is no record of active rehabilitation, home exercise, or functional restoration program.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less invasive conservative care measures. There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery without failure of all conservative treatment measures. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for right total knee arthroplasty (27447) 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve total knee arthroplasty for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110), periodic oral evaluation (D0120), 
bitewing x-rays (D0274), first intraoral periapical x-ray (D0220), and additional intraoral periapical x-ray 
provided on October 25, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the prophylaxis, periodic oral evaluation, bitewing x-rays, and intraoral 
periapical x-rays. You say that you were told your insurance would cover services provided by the new dentist. 
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. The Plan also says that you did not contact the Plan prior to 
the date of service to verify benefits and provider eligibility.
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 are responsible for 100% of the 
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay 
for the prophylaxis (D1110), periodic oral evaluation (D0120), bitewing x-rays (D0274), first intraoral 
periapical x-ray (D0220), and additional intraoral periapical x-ray provided on October 25, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the skin debridement procedures you had 
at an outpatient hospital facility on April 7, 2021, and April 14, 2021.
You asked the Plan to waive the copayments for the skin debridement procedures. You say that these services 
did not occur in the hospital, but in an outpatient clinic. The Plan denied your request. The Plan says you were 
charged these copayments 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 $100 
copayment for surgery and other services in an outpatient hospital facility. 
You have been asked to pay a $100 copayment for the skin debridement procedures. The skin debridement 
procedures fals within the surgery and other services in an outpatient hospital facility benefit category. This is 
because the clinic where you received these services is considered an outpatient hospital facility and they bill as 
an outpatient hospital facility. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayments for the skin debridement 
procedures you had at an outpatient hospital facility on April 7, 2021, and April 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room (ER) services you received from October 28, 2021, to October 29, 2021.  You asked the Plan to waive the copayment for the ER services. You say that you staued overnight, so there should be no 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 $120 copayment for emergency room services. This copayment is waived if you are admitted to the hospital within 24 hours.  You have been asked to pay a $120 copayment for the ER services. Records show that although you stayed overnight, you were never formally admitted to the hospital.  Because of this, the copayment is not waived. 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 emergency room (ER) services you received from October 28, 2021, to October 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composites (D2391) provided on September 
13, 2021.
You asked the Plan to pay for the resin-based composites. You say that this was essential work needed due to 
cancer surgery and radiation treatment affecting the tongue, mouth, and lymph
nodes. You also say that the resin composites require less of the natural tooth structure to be taken away, and 
are the standard of care and less invasive. The Plan denied your request. The Plan says this service is not a 
covered benefit under your dental plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resinbased composites (D2391) provided on September 13, 2021.