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

 We decided that the Plan does not have to pre-approve Calcip/Betam Sus.  You asked the Plan to pre-approve Calcip/Betam Sus. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.  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 Calcip/Betam Sus.       Benefits for Calcip/Betam Sus 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost share for the specialist office visit and the injection provided on August 11, 2021.  You asked the Plan to waive the cost share for the specialist office visit and the injection. You say that you have never had to pay this amount in the past and should not have to pay this amount now. The Plan denied your request. The Plan says you have been asked to pay 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 $40 copayment per visit to an in-network specialist and 20% coinsurance for in-network Part B drugs, including chemotherapy drugs.   You have been asked to pay a $40 copayment for the specialist office visit. You have also been asked to pay $158.12 which is 20% of the allowed amount for the injection. The allowed amount is $790.58. ($790.58 x 20% = $158.12). The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The injection 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 cost share for the specialist office visit and the injection provided on August 11, 2021.   Please note, our decision is only regarding the August 11, 2021, date of service. Please contact the Plan directly for any questions regarding previous years' billing.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, emergency transport (A0429) provided September 14, 2021.  You asked the Plan to waive the copayment for the emergency ambulance services. You say that you called the crisis line by mistake and did not want the ambulance transport. 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 $270 copayment per date of service regardless of the number of trips by ground ambulance.  You have been asked to pay a $270 copayment for the emergency ambulance services. This service falls within the Ambulance 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 the ambulance service, basic life support, emergency transport (A0429) provided September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an office visit (99213) provided on May 27, 2021.  You asked the Plan to waive the copayment for the office visit. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  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 $40 copayment for Physician/Practitioner Services, Including Doctor's Office Visits.     You have been asked to pay a $40 copayment for a specialist office visit. The record indicates that these services were performed by a gynecologist. 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 office visit (99213) provided on May 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Amlodipine.  You asked the Plan to pre-approve Amlodipine. You say that the medication is necessary. The Plan denied your request. The Plan says your plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.  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 Amlodipine.        Benefits for Amlodipine 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a cortisone injection of the knee (20610, G0463, J1030) rendered on June 23, 2021.  You asked the Plan to waive the copayment for a cortisone injection of the knee. You say that you made an appointment with the provider to see what could be done with the pain in your left knee. You also say you received a cortisone injection to help relieve the pain. You also say that no outpatient surgical services were received, and you believe you have been charged incorrectly. The Plan denied your request. The Plan says you were 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 $370 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges.    You have been asked to pay a $353, which is less than the $370 copayment for a cortisone injection of the knee. Cortisone injections of the knee fall within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers. 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 cortisone injection of the knee (20610, G0463, J1030) rendered on June 23, 2021.   Your complaint about the potentially poor customer service phone communications is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355).  You asked the Plan to pre-approve full mouth debridement. You say that the enrollee needs this service. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefits.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an office visit and an x-ray (99214, 76830) provided on June 18, 2021.  You asked the Plan to waive the copayment for the office visit and an x-ray. You say that the services should be covered as the doctor was too rough. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  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 $50 copayment for Outpatient diagnostic tests and therapeutic services and supplies and a $20 copayment for Physician/Practitioner services, including doctor's office visits  You have been asked to pay a $50 copayment and a $20 copayment for an office visit and an x-ray. Office visits fall within the Physician/Practitioner services, including doctor's office visits benefit category, while x-ray services fall under 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 an office visit and an x-ray (99214, 76830) provided on June 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Nucynta.  You asked the Plan to pre-approve Nucynta. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.  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 Nucynta.        Benefits for Nucynta 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Trelegy.  You asked the Plan to pre-approve Trelegy. You say that Trelegy is medically necessary. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Trelegy.   Benefits for Trelegy 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a resin-based composite (D2330), and a crown (D2740) provided by an out-of-network provider on June 22, 2021.  You asked the Plan to pay for a resin-based composite and a crown. You say that you do not believe you should be held responsible for this. You say that this amount is way too high. The Plan denied your request. The Plan says the dentist who provided these services is out-of-network.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a resin-based composite (D2330), and a crown (D2740) provided by an out-of-network provider on June 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prolia.  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 osteoporosis and has been on therapy with aledronate for five years. She has not tried and failed the Plan's required drugs, an oral bisphosphonate and zoledronic acid. The records do not show that the required drugs would be contraindicated or less effective; therefore, Prolia 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 Prolia.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the chest x-ray rendered on September 3, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 71045 is not separately payable.  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  The provider submitted a claim for procedure codes 71045 (chest x-ray, single view) and 71046 (chest x-ray, 2 views). Code 71045 is a column II code with a modifier indicator of 1 when billed with column I code 71046. Code 71045 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the chest x-ray rendered on September 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics.  You asked the Plan to pre-approve foot orthotics. You say that you have a leg discrepancy. 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 pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eliquis tablet 5mg 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 this is a self-administered drug.  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 Eliquis tablet 5mg for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pulp vitality tests (D0460), cone beam computed tomography (CT) capture and interpretation with limited field of view - less than one whole jaw (D0364), and limited oral evaluation - problem focused (D0140) provided August 25, 2021.  You asked the Plan to pay for the pulp vitality tests, cone beam CT scan and limited oral exam. You say that the provider did not inform you that they do not take Medicare. The Plan denied your request. The Plan says these services are not covered because the provider has opted out of Medicare.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the pulp vitality tests, cone beam CT scan and limited oral exam when you see any licensed dental provider who accepts Medicare patients in the United States and has not opted out of Original Medicare.  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 pulp vitality tests, cone beam CT scan and limited oral exam have not been met. Therefore, we decided that the Plan does not have to pay for the pulp vitality tests (D0460), cone beam computed tomography (CT) capture and interpretation with limited field of view - less than one whole jaw (D0364), and limited oral evaluation - problem focused (D0140) provided August 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a 2D oral/facial photographic image (D0350) provided by a participating provider on August 24, 2021.  You asked the Plan to pay for a 2D oral/facial photographic image. You say that all x-rays should be covered because it helps keep everyone healthy. The Plan denied your request. The Plan says the rendered dental x-ray is not a covered benefit.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 2D oral/facial photographic image (D0350) provided by a participating provider on August 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a duplex scan of extremity veins provided on July 29, 2021.  You asked the Plan to waive the copayment for the duplex scan. You say that you would like this bill taken care of. 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 $45 copayment for each diagnostic test.   You have been asked to pay a $45 copayment for the duplex scan. The duplex scan falls 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 duplex scan of extremity veins provided on July 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an interspinous decompression device.  You asked the Plan to pre-approve an interspinous decompression device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an interspinous decompression device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found interspinous process spacer devices remain experimental. More research is needed to show safety and efficacy.        We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an interspinous decompression device have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous decompression device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a resin-based composite (D2332) provided by a participating provider on July 26, 2021.  You asked the Plan to pay for a resin-based composite. You say that you believe the Plan should pay for this. The Plan denied your request. The Plan says the benefit limit for fillings has already been exhausted.  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 resin-based composites with a 50% coinsurance per calendar year.   We looked at the file and Medicare rules. Three fillings were provided. Two were covered with a 50% coinsurance of the allowed amount. The allowed amount is $307. The coinsurance for two fillings is $153.50. The third filling ($274) was denied due to exhausting this benefit limit. The total amount you are being asked to care is $427.50 ($153.50 + $274 = $427.50). Based on this information, we decided that the Plan's rules for coverage of a resin-based composite have not been met. Therefore, we decided that the Plan does not have to pay for a resin-based composite (D2332) provided by a participating provider on July 26, 2021.