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

We decided that the Plan does not have to pre-approve a Humira pen injector.
You asked the Plan to pre-approve self-administered drug. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
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 a Humira pen injector.
Benefits for self-administered 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the full cardiology genetic panel provided on May 13, 2021.

You asked the Plan to pay for the full cardiology genetic panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The full cardiology genetic panel at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the full cardiology genetic panel provided on May 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc.
You asked the Plan to pre-approve Orthovisc. You say that this is medically necessary. The Plan denied your request. The Plan says that you do not have a history of failure, contraindication, or intolerance to the formulary alternatives.
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 Orthovisc. Our reviewer says that Orthovisc is not medically reasonable and necessary for the enrollee. The Plan requires a trial of Synvisc, Durolane, and Gelsyn-3 before they will approve the requested drug. In this case, you have not tried and failed the required drugs. There is no documentation provided indicating that the Plan's required drugs would likely be less effective and/or likely have adverse effects for you. Our physician reviewer found that your condition does not meet step therapy criteria for Orthovisc. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Orthovisc.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on August 23,
2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the domiciliary or rest home visit. You say that the rendering physician is a
Hospitalist physician with the group and depends upon the hospital staff to verify eligibility and to obtain the
proper authorization from the enrollee's insurance company. You also say that the treating physician provided
medically necessary services to the enrollee in good faith. The Plan denied your request. The Plan says the
service was rendered by a non-network provider. The Plan also says that the service was not urgent or
emergent, nor was it approved in advance.

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.
Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit provided on
August 23, 2021 by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on March 3, 2021.

You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged.

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 laboratory services provided on March 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the leg provided on September 16, 2021. We also decided that the Plan does not have to waive the copayment for X-rays of the chest provided on September 16, 2021.
You asked the Plan to waive the copayment for the CT scan and X-rays. You say that your surgery was cancelled and you feel that you should not be responsible for these pre-operative tests. 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 a $150
copayment for each advanced radiology service, including CT scans. Your contract with the Plan also clearly says that you must pay a $30 copayment for each set of X-rays. You have been asked to pay $122.24, which is less than the $150 copayment for the CT scan. You have also been asked to pay a $30 copayment for the X-rays. The CT scan and X-rays fall 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 a computed tomography (CT) scan of the leg provided on September 16, 2021. We also decided that the Plan does not have to waive the copayment for X-rays of the chest provided on September 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cyclobenzaprine for the enrollee.
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 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 Cyclobenzaprine for the
enrollee.
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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (Denosumab).

You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage of Prolia.

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 Medicare criteria for coverage of Prolia are not met in this case. Our physician reviewer found the enrollee has not tried and failed a trial of Zoledronic acid. The documentation does not support that Zoledronic acid would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 

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 Prolia (Denosumab).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the repair of a broken complete maxillary denture base 
(D5512), repair of a resin mandibular partial denture base (D5611), and three removable prosthodontic 
procedures (D5899 x3) provided on May 13, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the complete maxillary denture base and resin mandibular partial denture base 
repairs and removable prosthodontic procedures. You say that the Plan's in-network providers were not 
interested in the dental work that you needed to have done. You also say that you believe you are entitled to 
reimbursement. The Plan denied your request. The Plan says these services were denied correctly because the 
treating provider is not a network provider. The Plan also says that services performed by a provider who is not 
in-network are not covered.

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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the repair 
of a broken complete maxillary denture base (D5512), repair of a resin mandibular partial denture base 
(D5611), and three removable prosthodontic procedures (D5899 x3) provided on May 13, 2021 by an out-of-
network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography scan (70450) provided on October 
4, 2021.

You asked the Plan to pay for a computed tomography scan. You say that the enrollee had multiple exams. The 
Plan denied your request. The Plan says this is not separately payable.

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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for a computed tomography scan (70450) provided on October 4, 
2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composites - one surface, anterior (D2330) 
and resin-based composites - two surfaces, anterior (D2331) provided September 1, 2021.

You asked the Plan to pay for the resin-based composites. You say that you chose the Plan for out-of-network 
benefits and were unaware that you had to check if a provider had opted out of Medicare. The Plan denied your 
request. The Plan says services rendered by providers who have opted out of Medicare are not covered.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care.

We looked at the file and Medicare rules. The services at issue in this appeal were provided in a non-urgent, 
non-emergent situation by the provider who has opted out of the Medicare program. Based on this information, 
we decided that the Plan's rules for coverage of the resin-based composites have not been met. Therefore, we 
decided that the Plan does not have to pay for the resin-based composites - one surface, anterior (D2330) and 
resin-based composites - two surfaces, anterior (D2331) provided September 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (70544) provided on August 10, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.

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, we have confirmed that code 70544 is a column II code to column I code 70551. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (70544) provided on August 10, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for a diagnostic ultrasound and a radiologic examination provided from March 29, 2021, through March 30, 2021.

You asked the Plan to pay for a diagnostic ultrasound and a radiologic examination. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

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 March 29, 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 a diagnostic ultrasound and a radiologic examination provided from March 29, 2021, through March 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on
January 14, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 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 services provided by an out-of-network provider on January
14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services provided to the enrollee on July 1, 2020.
You asked the Plan to pay for the services. You say that the claim should be reconsidered. The Plan denied
your request. The Plan says the claim was filed past the 12-month timeframe.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for the services was not filed until September 28, 2021. This means that more
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that
the Plan does not have to pay for surgical services provided to the enrollee on July 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on April 28, 2021.

You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services are not payable 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 find that CPT code G0483 is not supported in the medical record. Specifically, the place of service
on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The 
submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; 
however, the submitted medical documentation and/or claim history indicates that the specimen was obtained 
in an office setting, place of service 11. 

Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met.
Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on April 
28, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) coded 71250 provided on
September 9, 2021.
You asked the Plan to pay for the CT. You say that you would like the plan to reconsider their denial. The Plan
denied your request. The Plan says the services billed are not separately payable.
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, we have confirmed that code 71250
is a column II code to column I code 71275. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for the computed tomography (CT) coded 71250 provided on
September 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider
on September 16, 2021, and September 28, 2021.

You asked the Plan to pay for the services. You say that the in-network doctors were not going to give the
correct treatment. The Plan denied your request. The Plan says you self-referred for these services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the 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 services provided to you by an out-of-network provider on
September 16, 2021, and September 28, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the record does not show that the enrollee requires daily skilled nursing or skilled therapy in a SNF setting.
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 that the enrollee's condition does not meet Medicare criteria for SNF services. 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 skilled nursing facility (SNF) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown repair (D2980), limited oral evaluation (D0140),
intraoral radiographic images (x-ray) (D0220), and endodontic therapy (D3320), provided on July 6, 2021, and
July 7, 2021.
You asked the Plan to pay for the routine dental services. You say that the services should be covered. The Plan
denied your request. The Plan says Procedure code D2980 is not covered under the Member's contract under
any normal circumstances and Procedure code D0140 is a covered benefit, but the enrollee has exceeded limits
set in the subscriber agreement. Procedure code D0220 and D3320 are a covered benefit, but the enrollee
obtained these services through an out-of-network provider and is responsible for any amount over the Plan
allowed amount.
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. Procedure code D2980 is not covered under the Member's contract
under any normal circumstances and Procedure code D0140 is a covered benefit, but the enrollee has exceeded
limits set in the subscriber agreement. Procedure code D0220 and D3320 are a covered benefit, but the enrollee
obtained these services through an out-of-network provider and is responsible for any amount over the Plan
allowed amount. Therefore, we decided that the Plan does not have to pay for the crown repair (D2980),
limited oral evaluation (D0140), intraoral radiographic images (x-ray) (D0220), and endodontic therapy
(D3320), provided on July 6, 2021, and July 7, 2021.