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

We decided that the Plan does not have to pre-approve a bone graft, nasal, maxillary, or malar areas (21210) in
order to fit a dental implant for a fixed bridge.

You asked the Plan to pre-approve a facial bone graft. You say that this service is necessary to fix your teeth.
The Plan denied your request. The Plan says the requested service is dental in nature and is therefore not
covered by Original Medicare. The Plan also does not offer an additional benefit to cover dental care in excess
of Medicare coverage.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a bone graft, nasal,
maxillary, or malar areas (21210) in order to fit a dental implant for a fixed bridge.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient procedure provided on March 5, 2021.
You asked the Plan to waive the coinsurance for the outpatient procedure. You say you called the Plan and were told the surgery would be covered in-network. The Plan denied your request. The Plan says the claim processed correctly assessing a 20% co-insurance per the member's EOC. There were no extenuating circumstances to waive the co-insurance.
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 20% coinsurance for outpatient hospital services.
You have been asked to pay a 20% coinsurance for the outpatient procedure. The outpatient procedure falls within the outpatient hospital services 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 coinsurance for outpatient procedure provided on March 5, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Glucagon.
You asked the Plan to pre-approve Glucagon. You say that this is medically necessary. The Plan denied your
request. The Plan says that that the drug is not being prescribed for a medically-accepted indication.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan has not provided any medical records for review. Without medical
records we are unable to substantiate the Plan's medical necessity denial. Therefore, we decided that the Plan
has to pre-approve Glucagon.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair glide.
You asked the Plan to pre-approve a stair glide. You say that you are an amputee, and this will be an important tool for your recovery. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for various services received on August 24,
2020 and February 26, 2021.

You asked the Plan to waive the copayment for the services. You say that these injections are too close together
for the dates of service to pay for. The Plan denied your request. The Plan says the copayments were processed
appropriately.

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 for outpatient hospital services.

You have been asked to pay a $250 copayment for each of the services. The services fall within the outpatient
hospital services 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 various services
received on August 24, 2020 and February 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia injections.

You asked the Plan to pre-approve the Prolia treatment. You say that it is felt that this treatment is necessary. The Plan denied your request. The Plan says there is no evidence the preferred drug, zoledronic acid would be less effective.

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 the Prolia treatment. Our reviewer says that the requested drug is not considered medically necessary based on step therapy criteria. Our physician reviewer found the Plan requires a trial of Zoledronic Acid before they will approve the requested drug. In this case, the patient has not tried and failed the required drug. There is no documentation provided indicating that the Plan's required drug 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 the Prolia treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit (99203, 99213) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the office visit. You say that the services are medically necessary. The Plan denied your request. The Plan says there are network providers available. The services are not emergent.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office visit (99203, 99213) to be provided by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital physician services provided from October 30, 2020, to October 31, 2020.
You asked the Plan to pay for physician services. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the enrollee was enrolled in hospice on these dates of service and therefore the Plan is not responsible for payment.
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 hospital physician services provided from October 30, 2020, to October 31, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction by neurolytic agent.
You asked the Plan to pre-approve destruction by neurolytic agent. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet joint (medial branch) nerves are considered medically reasonable and necessary for patients who meet specific criteria.
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 destruction by neurolytic agent. Our reviewer says that the services are not medically necessary. Our physician reviewer found the member's records do not show that the last procedure improved the member's pain by at least 50% for 6 months or the member's ability to do daily activities by at least 50 percent. The requested repeat procedure is not supported without this pain relief. The requested service is supported when: 1) a treatment plan shows the region (upper, middle, or lower back) and levels of the member's spine to be treated, 2) no more than two levels of the member's spine will be treated on the same day, and 3) the procedure is planned between the C2-3 (neck) and L5-S1 (lower back) spinal levels. The member records do not show this. As such, the Local Coverage Determination Facet Joint Interventions for Pain Management L38773 is not met. The request for the coverage of CPT codes 64635/64636 is not medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of destruction by neurolytic agent have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.
You asked the Plan to provide coverage for additional routine transportation trips. The Plan denied your request. The Plan says the Plan covers 96 one-way trips per calendar year and the 97th trip and beyond is not a covered benefit.
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. We looked at your request, the records in the case file, and the rules. The file shows that the Plan covers up to 96 one-wat trips per calendar year. The 97th trip and beyond is not a covered benefit. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the continuous positive airway pressure (CPAP) device and supplies provided April 20, 2020 to December 24, 2020.
You asked the Plan to waive the copayment for CPAP device and supplies. You say that no one ever told you about a 20% charge on your part for the use of the CPAP machine. The Plan denied your request. The Plan says these claims were processed with the correct cost share applied per the Evidence of Coverage.
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% of the cost for each Medicare covered item, except blood glucose monitors. You have been asked to pay $338.77 ($18.57 + $28.20 + $28.20 + $28.53 + $28.20 + $1.06 + $39.43 + $1.06 + $28.20 + $28.20 + $28.20 + $28.20 + 24.52 + $28.20) for the CPAP device and supplies. The CPAP device and supplies fall within the Durable medical equipment (DME) and related 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 the continuous positive airway pressure (CPAP) device and supplies provided April 20, 2020 to December 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for an injection of hyaluronan (a Part B drug) and an orthopedic office visit provided on December 18, 2019 and January 14, 2020.
You asked the Plan to waive the cost-sharing for Part B drug and specialist visit. You say that you never previously paid for services at this doctor's office and feel these charges should be waived. The Plan denied your request. The Plan says the cost-sharing amounts you are being charged are correct.
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 Part B drug and $45 copayment for specialist visit. The allowed amount of the Part B drug is $769.51, resulting in a coinsurance amount of $153.90. Your total cost-sharing amount is therefore $198.90. You have been asked to pay 20% coinsurance for Part B drug and $45 copayment for specialist visit. Part B drug and specialist visit fall within the "Medicare Part B Prescription Drugs" and "Physician/Practitioner Services, Including Doctor's Office Visits" benefit categories. 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 an injection of hyaluronan (a Part B drug) and an orthopedic office visit provided on December 18, 2019 and January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for patient home visit provided on May 12, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the patient home visit. You say that you were referred from the hospital. The Plan denied your request. The Plan says this is not a network provider with the Plan.
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 patient home visit provided on May 12, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that the enrollee needs for assistance showering. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on April 7, 2021.
You asked the Plan to pay for foot orthotics. You say that you physician prescribed orthotics for you post-surgery. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on April 7, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that you did not have a no show and should have more transportation trips. The Plan denied your request. The Plan says that no additional rides above 24 one-way trips are covered.
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 covers a maximum of twenty-four (24) trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan does not have to provide routine transportation above the benefit maximum of twenty-four (24) routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve replacement dentures.
You asked the Plan to pre-approve replacement dentures. You say that the service at issue is necessary. The Plan denied your request. The Plan says replacement dentures prior to eligibility are not approved.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of replacement dentures have not been met. Specifically, the record shows you received your current dentures on November 30, 2016. Therefore, we decided that the Plan does not have to pre-approve replacement dentures.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an endoscopy with injections (91040,
43236, J0585) provided April 22, 2021.
You asked the Plan to waive the copayment for the endoscopy with injections. You say that the procedure did
not help and the copayment should be waived. The Plan denied your request. The Plan says the correct costsharing
was applied.
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 $325
copayment for Outpatient Surgery.
You have been asked to pay a $325 copayment for the endoscopy with injections. The endoscopy with
injections falls within the Outpatient Surgery 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 an endoscopy with injections (91040, 43236, J0585) provided April 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital or ambulatory surgical center call (D9420) and
extraction, erupted tooth or exposed root (D7140) provided April 22, 2021.
You asked the Plan to pay for the dental services. You say that you believe the services should be reimbursed
due to the fact that there was no longer another oral surgeon in the town. The Plan denied your request. The
Plan says the services were rendered by a provider who has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for the hospital or ambulatory surgical
center call (D9420) and extraction, erupted tooth or exposed root (D7140) provided April 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an abutment supported porcelain/ceramic crown (D6058).
You asked the Plan to pre-approve an abutment supported crown. You say that you have not had any implants or crowns in 2021. The Plan denied your request. The Plan says you have exceeded frequency limits for this service in 2021.
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 two abutment supported crowns per calendar year. We looked at the file and Medicare rules. The Plan provided documentation that you received and were covered for two abutment supported crowns on January 7, 2021. Based on this information, we decided that the
Plan's frequency limit for coverage of an abutment supported crown has been exceeded. Therefore, we decided that the Plan does not have to pre-approve an abutment supported porcelain/ceramic crown (D6058).