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

 We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve these OON services. You say that you have seen this provider for a long time, and you were under the impression that you could continue seeing your providers. The Plan denied your request. The Plan says the requested services can be provided by a network provider.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fixed partial denture sectioning (D9120) and interim partial upper denture (D5820).

You asked the Plan to pre-approve the dental services. You say that your dentist advised that an interim denture was necessary to allow you time to heal from the extractions. The Plan denied your request. The Plan says fixed partial denture sectioning is not listed as a covered service. The Plan says that interim partial upper denture is not listed as a covered service either.

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 dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a fixed partial denture sectioning (D9120) and interim partial upper denture (D5820).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve abutment supported porcelain fused to metal crowns (high noble metal) (D6059) for teeth 2 and 3.  You asked the Plan to pre-approve the abutment supported crowns. You say that the enrollee needs this service. The Plan denied your request. The Plan says you have exceeded the frequency limit for this 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. The Plan covers abutment or implant supported crowns and retainers twice per calendar year.   We looked at the file and Medicare rules. The Plan provided documentation showing that two implant supported crowns were covered on April 9, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of two abutment supported crowns has been exceeded [Therefore, we decided that the Plan does not have to pre-approve abutment supported porcelain fused to metal crowns (high noble metal) (D6059) for teeth 2 and 3.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral exam (D0120) and cleaning (D1110) provided on July 1, 2021, by an out-of-network provider.

You asked the Plan to pay for the dental services. You say that your contract says that there is a $0 copayment for dental cleanings in-or-out of network and you should not have to pay for these services just because they were provided out-of-network. The Plan denied your request. The Plan says this claim was processed in accordance with your contract. The Plan has paid the full allowed cost for these services, but you are responsible for the difference between what the provider billed and what the Plan can pay for services because you chose to see an out-of-network provider.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). 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. Your contract with the Plan' clearly says that you must pay a $0 copayment for covered preventative and diagnostic dental services provided in-network or out-of-network. However, you will save more when you receive care from an in-network dental provider. You can get care from an out-of-network dental provider, but you may pay more.

You have been asked to pay $55 for the oral exam and cleaning provided on July 1, 2021, by an out-of-network provider. Documentation shows that the provider in question billed the Plan $51 for the exam, and $118 for the cleaning, for a total of $169. The Plan's maximum allowed cost for these services is $40 for the exam and $74 for the cleaning for a total of $114. The Plan has paid the full allowed cost of these services. This is the amount that an in-network provider would accept as full payment for this care, but out-of-network providers do not have this agreement with the Plan and are allowed to charge you for the difference between what the Plan pays and what is billed ($169 - $114 = $55). Because the Plan paid the full allowed cost for this care, you are responsible for a $0 copayment on this amount. However, the out-of-network provider billed $55 in excess of this amount, and you are responsible for this part of the bill. 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 pay the remaining cost for the periodic oral exam (D0120) and cleaning (D1110) provided on July 1, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit with a specialist (99213) provided on August 17, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for an office visit with a specialist. You say that this patient was referred to your facility from the hospital and your facility's providers are contracted with the hospital to accept patients with this Plan. The Plan denied your request. The Plan says this provider is not a network provider with the Plan. The Plan also says that the services were not referred by a network provider or rendered in a participating facility. The Plan says that they have also determined that these services were not urgent or emergent, nor were they 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 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 an office visit with a specialist (99213) provided on August 17, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergency transportation, wheelchair van provided on June 9, 2021.

You asked the Plan to pay for non-emergency transportation, wheelchair van. You say that the service was medically necessary. The Plan denied your request. The Plan says this service is not covered by the Plan.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services. 

The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided that the Plan does not have to pay for non-emergency transportation, wheelchair van provided on June 9, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for a colonoscopy (G0150) provided on July 23, 2021.  You asked the Plan to pay for the colonoscopy. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were provided out-of-network and were non-emergent. There were network providers available.  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 service 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 a colonoscopy (G0150) provided on July 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computerized tomography (CT) scan coded 70450 provided on July 30, 2021.  You asked the Plan to pay for the CT scan. 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 70450 for the CT scan 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 the computerized tomography (CT) scan coded 70450 provided on July 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Aduhelm.

You asked the Plan to pre-approve Aduhelm. You say that this therapy is likely to reduce amyloid plaques and delay cognitive delay for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because Aduhelm is considered experimental/investigational.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 Aduhelm. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of Aduhelm. Our physician reviewer found the Food & Drug Administration (FDA) says that Aduhelm is approved based on reduction in amyloid beta plaques observed in patients. The documentation does not show that the enrollee has amyloid beta plaques. The requested use of Aduhelm is not supported by one of the major drug compendia or by clinical research appearing in a Medicare-approved medical journal. There is evidence of mixed etiology of the enrollee's symptoms. It has not been demonstrated that Aduhelm is at least as beneficial as the existing medically appropriate alternatives that the enrollee is taking.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Aduhelm.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vimpat tablets.

You asked the Plan to pre-approve Vimpat tablets. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says Vimpat tablets are not covered under the enrollee's Medicare Part B 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 Vimpat tablets.

Benefits for Vimpat tablets 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services without transport (A0998).

You asked the Plan to pay for ambulance services without transport. You say that this should be covered. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on June 20, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance services without transport (A0998).
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health services (G0151, G0157, G0299) provided to the enrollee from July 9, 2021 to August 7, 2021.  You asked the Plan to pay for home health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed.  The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.  We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, no RAP claim was submitted for the home health services at issue. Therefore, we decided that the Plan does not have to pay for the home health services (G0151, G0157, G0299) provided to the enrollee from July 9, 2021 to August 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Gel One.  You asked the Plan to pre-approve Gel One. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.    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 Gel One. Our reviewer says that the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer found the enrollee has osteoarthritis of the knee. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternative. Therefore, the enrollee does not meet criteria for the requested drug.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gel One have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel One.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy evaluation services (97162) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve physical therapy evaluation services. You say that this care from an OON provider is medically necessary. The Plan denied your request. The Plan says there are OON providers available to treat the enrollee's condition.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal.

We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve physical therapy evaluation services (97162) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eyeglasses provided on May 22, 2021.  You asked the Plan to pay for the eyeglasses. You say that you purchased new glasses and are appealing the denial. The Plan denied your request. The Plan says coverage cannot be provided for eyeglasses purchased from a non-participating provider.   Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are received from the Plan's vision provider.  We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Specifically, the eyeglasses were not purchased from the Plan's vision provider. Therefore, we decided that the Plan does not have to pay for the eyeglasses provided on May 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist visits and does not have to waive the coinsurance for chemotherapy provided from June 23, 2021, to July 14, 2021.

You asked the Plan to waive the copayments for specialist visits and to waive the coinsurance for chemotherapy. You say that you cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 copayment for specialist services.

Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. 

You received specialist services on June 23, 2021. Therefore, you are responsible to pay the $25 copayment. 

You received chemotherapy on June 23, 2021. The total allowed amount is $10,323.20 and 20% of that is $2,064.64. 

You received specialist services on July 14, 2021. Therefore, you are responsible to pay the $25 copayment. 

You received chemotherapy on July 14, 2021. Therefore, you are responsible to pay $670.36, which is less than the 20% coinsurance amount. 

The total amount you owe is: $2,785.

You have been asked to pay the total amount of $2,785 for specialist visits and chemotherapy. Specialist visits fall within the physician/practitioner services, including doctor's office visits benefit category. Chemotherapy falls within the Medicare Part B prescription drugs 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 copayments for specialist visits and does not have to waive the coinsurance for chemotherapy provided from June 23, 2021, to July 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve insertion of a dual chamber pacemaker.  You asked the Plan to pre-approve dual chamber pacemaker. You say that a dual chamber pacemaker is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan follows Medicare rules. Medicare rules say that a dual chamber pacemaker is subject to the criteria listed 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 dual chamber pacemaker. Our reviewer says that the requested dual chamber pacemaker is not medically reasonable and necessary according to the Medicare rules. Our physician reviewer found that at issue is the medical appropriateness and necessity for implantation of a cardiac pacemaker in the setting of syncope of unclear etiology. While he has bifascicular block on electrocardiogram (ECG), ambulatory ECG monitoring has been unremarkable. The physician's plan was to carry out an electrophysiologic study to assess whether an identifiable abnormality might confirm a rhythmic etiology of syncope and in that case implant a dual chamber pacemaker. Also proposed was that if the electrophysiological study were negative, then he would request authorization for implantation of a loop recorder (ILR). Insertion of an ILR would be appropriate in light of the suspected bradyarrhythmic etiology of syncope; however, in the absence of confirmatory evidence, the patient does not currently meet criteria established by guidelines to recommend implantation of a pacemaker. As a result, at this time pacemaker implantation would not be considered medically reasonable and necessary in this patient's clinical management.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of dual chamber pacemaker have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of a dual chamber pacemaker.