Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99326) rendered by the out-of-network (OON) provider on March 3, 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 domiciliary or rest home visit (99326) rendered by the out-of-network (OON) provider on March 3, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to hold you harmless for the resin-based composite (D2392) on tooth #13
provided on May 19, 2021.
You asked the Plan to pay for the resin-based composite. The Plan denied your request. The Plan says that this
service is a covered benefit, but you have exceeded the limits set in the subscriber agreement.
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. Medicare rules say that a
contract provider is an agent of the plan. Services and referrals given by a contract provider are considered
approved by the plan unless notice is provided that the services will not be covered. The Plan follows these
rules.
The contract says that within two years of a restoration there will only be one justified remake or restoration.
The Plan contract also says that if the same dentist/office needs to redo a previous restoration and add
additional surfaces within six months, only the added surfaces will be considered. The record shows that the
buccal filling of tooth #13 was provided more than six months before this May 19, 2021, date of service. The
resin-based composite was also rendered by an in-network provider. The contract does not clearly say that if
the restoration needs to be remade and it is not found to be justified, that you would be held responsible for the
payment. Therefore, we decided that the Plan has to hold you harmless for the resin-based composite (D2392)
on tooth #13 provided on May 19, 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Simponi Aria.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found you have a diagnosis of rheumatoid arthritis. You have not tried and failed the Plan's required drugs of Enbrel, Humira, Rinvoq, or Xeljanz. The records do not show that the required drugs would be less effective or have adverse effects; therefore, the Simponi Aria is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Simponi Aria.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional non-emergency transportation trips.
You asked the Plan to pre-approve additional non-emergency transportation trips. You say that you still have 2 pending appointments and do not have your own transportation. You say that you are requesting help to keep these appointments. The Plan denied your request. The Plan says you are only covered for 24 one-way trips per year.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan only covers 24 routine transportation trips each year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional non-emergency transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the Stelara injections you received as well as drug administration services you receive at an outpatient hospital facility on September 16, 2020, and December 9, 2020.
You asked the Plan to waive the cost sharing for the Stelara injections. You say that when you received the first injection of this drug in June of 2020, you were only charged a $10 copayment. You say that you were told that these shots would be covered. You said that you cannot afford the high cost. The Plan denied your request. The Plan says you were charged this cost sharing correctly. The Plan says that you were appropriately charged 20% coinsurance for the drug itself. The Plan also says that since the administration service was provided at an outpatient hospital, you are responsible for the outpatient hospital copayment. The allowed amount for the administration service is $90.53, which is less than your copayment obligation for that portion, so you are responsible for this full allowed amount for the administration service.
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 Medicare Part B drugs and a $370 copayment for services at an outpatient hospital facility. You have been asked to pay 20% coinsurance for the Stelara injections. Records show that the allowed amount for the Stelara injection you received on September 16, 2020, is $16,941.60. You were charged 20% coinsurance on this allowed amount, for a total of $3,388.32. For date of service December 9, 2020, the allowed amount for the Stelara injection was $16,592.40. The coinsurance based on that allowed amount is $3,318.48, however, you only had $3027.96 remaining on your maximum out-of-pocket as of that date, so that is all you are being charged for the Stelara injection you received on that date. In addition to the injection itself, you received an administration service at the hospital where you received the Stelara. This is a separate fee from the drug itself. According to your Evidence of Coverage, you have a $370 copayment for surgery or other services you receive at an outpatient hospital facility. You were charged the allowed amount of $90.53 for this administration service because the allowed amount is less than your copayment. 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 cost sharing for the Stelara injections you received as well as drug administration services you receive at an outpatient hospital facility on September 16, 2020, and December 9, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to hold you harmless for a crown (D2750) provided on May 17, 2021.

You asked the Plan to reimburse you for a crown. You say that the service was necessary. The Plan denied your request. The Plan says that criteria was not met for coverage of the service at issue.

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 rules also say that for a service or item that is normally not covered, but could be covered under some conditions, the EOC alone is not adequate notice of non-coverage. If no notice of non-coverage is given, the enrollee is held harmless. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a crown have been met. The crown was provided by a contract provider. The service is a covered benefit of the Plan and is covered under some conditions. This means that the EOC is not adequate notice of non-coverage in this case. The file does not show that the Plan provided notice that these services would not be covered. Under Medicare rules, this means that the crown is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for a crown (D2750) provided on May 17, 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan
rendered on September 14, 2020.
You asked the Plan to waive the copayment for these services. You say that you should not be receiving the
bill. The Plan denied your request. The Plan says the copayment was applied 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 $250
copayment per day for Medicare-covered diagnostic radiology services (such as CT).
Review of the file shows that you received a CT scan on September 14, 2020. Per the contract with the Plan,
there is a $250 copayment per day for Medicare-covered diagnostic radiology services (such as CT).
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the
Medicare allowed amount for these services was $179.07. Given that the allowed amount was less than the
$250 copayment, you have been asked to pay $179.07 for these services.
Therefore, we decided that the Plan does not have to waive the copayment for the computed tomography (CT)
scan rendered on September 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cast metal frame partial upper denture.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the criteria for coverage are not 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 these 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records do not support that the Plan's criteria for coverage of the denture are met. Partial dentures are approved only when they are required to alleviate a serious health condition. The records show that only tooth #14 was to be replaced on the appliance. The Plan limits dentures to one missing upper or two missing lower teeth only. The denture is therefore not covered. 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a cast metal frame partial upper denture.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on May 4, 2021.
You asked the Plan to pay for out of network services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network physician services provided on May 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aduhelm 170mg/1.7 ml vial for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the coverage criteria is not currently met.
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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the requested drug is indicated for the treatment of Alzheimer's disease in patients with mild cognitive impairment or the mild dementia stage of the disease. The documentation in the case file does not support that the enrollee has a diagnosis of mild cognitive impairment or mild dementia for which the drug is indicated. The documentation does not support that the drug would be safe and effective 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 the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Aduhelm 170mg/1.7 ml vial for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for inpatient physician services you had on
April 4, 2021, and April 5, 2021.
You asked the Plan to waive the deductible for the inpatient physician services. You say that this deductible
should be waived because your treatment was related to the Coronavirus. The Plan denied your request. The
Plan says you were charged this deductible correctly. The Plan says that cost sharing applies to Coronavirusrelated
treatment.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $500 deductible which applies to inpatient hospital care.
You had not yet met your deductible at the time of these services. The Plan has followed Medicare rules by
clearly disclosing in the contract that there is a $500 deductible which applies to inpatient hospital care. There
is no provision in your contract stating that cost sharing is waived if your care is related to Coronavirus
treatment.
This cost sharing is a contractual obligation that had not been met at the time the inpatient physician services
was received on April 5, 2021. Therefore, we decided that the Plan does not have to waive the deductible for
inpatient physician services you had on April 4, 2021, and April 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services.
You asked the Plan to pre-approve the dental services. You say that you have pain in your mouth. The Plan denied your request. The Plan says the services 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.
The file shows that a core buildup, antimicrobial agents, and gingival irrigation were requested. Although the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.
The file also shows that a porcelain crown for tooth #21 was requested. We looked at the file, and Medicare rules. A crown for tooth #11 was previously authorized. Your plan only covers 1 crown procedure per calendar year. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve the requested dental services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has primary osteoarthritis of the knee. She has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do not show that the required drugs would be contraindicated or less effective; therefore, Euflexxa is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services rendered on May 15, 2021.
You asked the Plan to waive the copayment for these services. You say that you should have no copayment. The Plan denied your request. The Plan says the copayment was applied 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 $10 copayment per day for other Medicare-covered laboratory tests that are not FIT tests.
Review of the file shows that you received laboratory services on May 15, 2021. You have been asked to pay a $10 copayment per day for these services. These services fall within the other Medicare-covered laboratory tests that are not FIT tests 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 the laboratory services rendered on May 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided on December 29, 2020.
You asked the Plan to pay for critical care services. You say that you want the Plan to pay for these services. The Plan denied your request. The Plan says the code billed for this date of service is not supported.
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 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 critical care services. Our reviewer says that services provided on December 29, 2020 do not meet criteria for billing or reimbursement consideration.
Our reviewer found the medical records provided does not include a documented total time that critical care services were provided, therefore this service does not meet the critical care guidelines in accordance with the code definition, therefore, this service 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 critical care services have not been met. Specifically, the medical records submitted do not include sufficient documentation to verify a documented total time that critical care services were provided. Therefore, we decided that the Plan does not have to pay for critical care services (99291) provided on December 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out-of-network physician services provided on March 29,
2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.
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 items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for out-of-network physician services provided on
March 29, 2021.