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

We decided that the Plan does not have to waive the copayments for the multiple ultrasounds provided on February 12, 2020.You asked the Plan to waive the copayments for the multiple ultrasounds. You say that you were billed an incorrect amount 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 $135 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic). You have been asked to pay a total of $337.61 copayment for the multiple ultrasounds. The multiple ultrasounds fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayments for the multiple ultrasounds provided on February 12, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist office visit provided on February 28, 2020.You asked the Plan to waive the copayment forthe specialist office visit. You say that this bill was for a follow-up visit to have stitches removed. You say you were told to send the bill in and it would be 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 $35 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office. You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to a surgical procedure.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 forthe specialist office visit provided on February 28, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation and periodontal maintenance provided on September 5, 2018.
You asked the Plan to pay for the comprehensive oral evaluation and periodontal maintenance. You say that the dentist couldn't find any information to file the claim. You say that you are wondering who is going to pay the amount insurance didn't pay. The Plan denied your request. The Plan says a claim is denied if it is not received by the Plan within 12 months.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for the comprehensive oral evaluation and periodontal maintenance was not filed until December 10, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation and periodontal maintenance provided on September 5, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.
You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your request. The Plan says that no current documentation was submitted.
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 Prolia. Our reviewer says that Prolia is not medically reasonable and necessary for the enrollee in this case. Based on the results of a 2015 bone density test, the enrollee does have osteoporosis. A January 2019 office note indicates that the enrollee was taking Prolia. There is no evidence that the enrollee tried and failed or is allergic to other osteoporosis medications. None of the documentation notes an assessment or plan regarding the enrollee's osteoporosis. There is no evidence that a follow up bone scan to assess the efficacy of prior treatment has been completed. As such, the documentation is insufficient to support that the request for Prolia is currently medically necessary or reasonable. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Prolia. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia for the enrollee.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Keytruda injection (pembrolizumab).You asked the Plan to pre-approve Keytruda injection (J9271).You say that the markers are on the report and were stable.The Plan denied your request. The Plan says that the certain marker is not found on the enrollee's cells.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 Keytruda injection (J9271).Our reviewer says that criteria is met for this drug. Our physician reviewer found this review relates to a request for Keytruda (Pembrolizumab) to be given with Lenvatinib to treat an enrollee with  metastatic endometrial cancer that is MMR proficient and MSI stable.The requested use is FDA approved.Per the FDA website, Keytruda in combination with Lenvatinib, is indicated for the treatment of patients with advanced endometrial carcinoma that is not MSI-H or dMMR, who have disease progression following prior systemic therapy and are not candidates for curative surgery or radiation. The enrollee meets that criteria. The enrollee's tumor is not MSI-H or dMMR, it is MSI stable and MMR proficient. Therefore,the requested use is medically reasonable and necessary for the enrollee. The documentation supports that the requested use is safe and effective 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 Keytruda injection (J9271)have been met.Therefore, we decided that the Plan has to pre-approve Keytruda injection (pembrolizumab).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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the perfusionist services provided on November 25, 2019.
You asked the Plan to pay for the services provided. You say that the charges are for the perfusionist that setup and operated the heart-lung machine for the enrollee's surgery. The Plan denied your request. The Plan says the facility must furnish all necessary covered services to the enrollee either directly or under arrangements made between the facility and outside vendors.
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility for services furnished to a beneficiary. We looked at the file and Medicare rules. The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This service was provided via arrangement of the facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the perfusionist services provided on November 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveoutpatient physician services to be provided by an out of network (OON) provider.You asked the Plan to pre-approveoutpatient physician services. You say that you have had no luck with in-network providers.The Plan denied your request. The Plan says there are still in-network providers available for these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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-approveoutpatient physician services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the service is available within the primary network, and the enrollee's condition is not an emergency.
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 a referral to an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal ultrasound rendered on March 16, 2020.
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 the claim is a duplicate.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 pay for the abdominal ultrasound rendered on March 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the records provided support the need for IRF care. The Plan denied your request. The Plan says the enrollee does not need an intensive team approach to care. The Plan say that the enrollee does not need to be seen by a rehab doctor 3 times a week. The Plan says that the enrollee does not need an inpatient rehab stay to get better. The Plan says that the enrollee can safely receive the care needed in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that the enrollee's functional status requires an intensive rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the duplex scan of the lower extremities (93925) to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the duplex scan. You say that these services are medically necessary.The Plan denied your request. The Plan says the services are not emergent. There are several network providers available who can provide the services at issue.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 the duplex scan of the lower extremities (93925) to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing provided on March 23, 2020.
You asked the Plan to pay for the laboratory testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore,
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on September 11, 2019.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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay for the drug testing rendered on September 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on May 7, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay for the drug testing rendered on May 7, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone scan (78306).You asked the Plan to pre-approve the bone scan. You say that the bone scan is medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that SPECT imaging is covered when medically 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 bone scan. Our reviewer says that the requested SPECT bone scan is not medically necessary. Our physician reviewer found the enrollee has no known malignancy history other than a basal cell skin cancer that was removed. Based on the medical records provided, the bone scan is not supported at this time.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 bone scan have not been met.Therefore, we decided that the Plan does not have to pre-approvea bone scan (78306).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Vertiflex Superion Interspinous Spacer (22869 and 22870).
You asked the Plan to pre-approve the insertion of a Vertiflex Superion Interspinous Spacer. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental.
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 the insertion of a Vertiflex Superion Interspinous Spacer. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is 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 the insertion of a Vertiflex Superion Interspinous Spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex Superion Interspinous Spacer (22869 and 22870).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea crown (D2740) and trigeminal division block anesthesia (D9212).You asked the Plan to pre-approvethe crown and trigeminal division block anesthesia. You say that you must take preventive measures ofdental hygiene so as not to have major complications. You also say that you have very few teeth left.The Plan denied your request. The Plan says these services are not covered 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-approvea crown (D2740) and trigeminal division block anesthesia (D9212).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you have been using your spouse's oxygen and want to have your own. The Plan denied your request. The Plan says you do not meet the guidelines for a portable oxygen concentrator.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep. To qualify for home oxygen, the patient must meet one of the following blood gas levels: 1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep;
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise; 4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia. For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage. We looked at the file and Medicare rules. The record shows your oxygen saturation is above 90% on room air. Based on this information, we decided that Medicare rules for coverage of a portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.