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

We decided that the Plan does not have to pay for a Hepatitis A and hepatitis B vaccine (90636) provided on
December 4, 2019.
You asked the Plan to pay for the vaccine. You say that you would like reconsideration because this vaccine
was prescribed as a preventative measure for travel. The Plan denied your request. The Plan says the services
performed are not covered under regular Medicare Part B and therefore are not covered by your Part B health
care plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The
Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to the vaccine.
Therefore, we decided that the Plan does not have to pay for a Hepatitis A and hepatitis B vaccine (90636)
provided on December 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar orthosis provided to enrollee on October 15, 2019.You asked the Plan to pay for the orthosis. You say that you confirmed the enrollee wants the braces they order.The Plan denied your request. The Plan says there must be information in the medical records to support medical necessity.The Plan must follow Medicare rules. Medicare rules say that orthosis are only covered under certain medical indications.We looked at the file and Medicare rules. In this case, there were insufficient records to substantiate the necessity for the provided orthosis. 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 lumbar orthosis provided to enrollee on October 15, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a replacement of BiPap (E0471) and humidifier (E0562).
You asked the Plan to pre-approve a replacement of BiPaPp and humidifier. You say that the current machine is from 2013 and is no longer able to be repaired. The Machine won't turn on due to an error code popping up on the machine. Download cannot be done on a broken machine. The Plan denied your request. The Plan says that the enrollee does not meet medical criteria.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 a replacement of BiPap and humidifier. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found The member meets criteria for replacement of his CPAP equipment as his current unit is not functioning properly and has been evaluated without determination in terms of cause or evidence that it can be repaired. He continues to be treated with diagnoses of obstructive sleep apnea. Replacement of his unit is medically reasonable and 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 a replacement of BiPap and humidifier have been met. Therefore, we decided that the Plan has to pre-approve a replacement of BiPap (E0471) and humidifier (E0562).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital outpatient clinic visit provided on September 10,
2019.
You asked the Plan to pay for the hospital outpatient clinic visit. The Plan denied your request. The Plan says
that the Plan requires utilization of network providers when possible and available, and requires authorization
for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency
situation, has been documented.
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 did not pre-approve the
hospital outpatient clinic visit. 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 hospital outpatient clinic visit provided on
September 10, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Avastin (bevacizumab) used in combination with nivolumab on October 22, 2019.
You asked the Plan to pre-approve the Avastin treatment. You say that this should be covered due to medical necessity. The Plan denied your request. The Plan says the use of Avastin in the regimen provided is not considered reasonable and necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 the Avastin treatment. Our reviewer says that the use of Avastin in this chemotherapy regimen is not considered reasonable and necessary. Our physician reviewer found the enrollee has stage IV hepatocellular carcinoma. The disease is microsatellite stable, low TB, with PDL-1 of O. The enrollee was started on first line nivolumab on April 19, 2019 and Avastin was added. The use of Avastin in this circumstance is not FDA-approved. There is also no support for this combination in the major drug compendia or in clinical research in a CMS-approved medical journal. The only combination found to be supported is Avastin with atezolizumab, not nivolumab. 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 Avastin treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve Avastin (bevacizumab) used in combination with nivolumab on October 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to approve additional reimbursement for the lenses and anti-reflective
lens coating provided on October 15, 2019.
You asked the Plan to approve additional reimbursement for the lenses and anti-reflective lens coating. The
Plan denied your request. The Plan says that you exhausted your $100 eyewear benefit with this purchase.
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 up to a $100 allowance for eyeglasses and contact lenses.
We looked at the file and the Plan's rules. The file shows that the plan has approved the maximum yearly
benefit of $100 for the requested services. There is no provision in the contract which would require the plan to
approve more than this amount. Therefore, we decided that the Plan does not have to approve additional
reimbursement for the lenses and anti-reflective lens coating provided on October 15, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from October 4, 2019 to October 16, 2019.
You asked the Plan to pay for the home health services. You say that this is being incorrectly processed as an episodic claim when it must be paid as a per-visit claim. The Plan denied your request. The Plan says the claim does not include required information regarding the location of where services were rendered.
The Plan must follow Medicare rules. Medicare rules say that HHAs must report value code 85 with the FIPS code for the state and county in which the services were rendered. We looked at the file and Medicare rules. The claim does not include value code 85. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to pay for the home health services provided from October 4, 2019 to October 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for myocardial perfusion imaging provided on
December 9, 2019.
You asked the Plan to waive the coinsurance for myocardial perfusion imaging. You say that the test was
necessary for a procedure. 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 $200
copayment for diagnostic radiology provided by providers other than your primary care physician.
You have been asked to pay a $200 copayment for myocardial perfusion imaging. Myocardial perfusion
imaging 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 coinsurance for myocardial perfusion imaging provided on December 9,
2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on July 26, 2019. You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized. 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 services in question require prior authorization. The Plan did not pre-approve the 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 the medical services provided to the enrollee by an out-of-network provider on July 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the full mouth debridement, periodic oral evaluation, and prophylaxis provided by an OON provider on October 16, 2019. You asked the Plan to pay for the full mouth debridement, periodic oral evaluation, and prophylaxis. You say that a Plan representative told you that this provider was in-network. The Plan denied your request. The Plan says full mouth debridement is not a covered benefit under your dental plan. The Plan also says that your member liability for the periodic oral evaluation and prophylaxis were applied correctly.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, full mouth debridement is not among those covered under this benefit. The contract also says that you are responsible for the difference between the billed amounts and allowed amounts for the periodic oral evaluation and prophylaxis because they were received by an out-of-network provider. The record shows that you never asked about the network status of this provider when you spoke with the Plan representative. Therefore, we decided that the Plan does not have to pay for the full mouth debridement, periodic oral evaluation, and prophylaxis provided by an OON provider on October 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the medical eye exam provided on December 3, 2019. You asked the Plan to waive the cost share for the medical eye exam. You say that you were told the testing was 100% covered, besides the $45 copayment. You say you should not be responsible for anything further. 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. Your contract with the Plan says that there is a $250 in-network deductible that applies towards in-network medical eye exams and a $45 copayment for each in-network Medicare covered exam to diagnose and treat diseases or conditions of the eye after your yearly deductible is met. The medical eye exam you asked the Plan to waive the cost share for falls within the "Vision care" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 in-network deductible that applies towards in-network medical eye exams and a $45 copayment for each in-network Medicare covered exam to diagnose and treat diseases or conditions of the eye after your yearly deductible is met. This cost sharing is a contractual obligation that had not been met at the time the medical eye exam was received on December 3, 2019.Therefore, we decided that the Plan does not have to waive the cost share for the medical eye exam provided on December 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation provided on December 2, 2019. You asked the Plan to pay for the bone replacement graft for ridge preservation. You say that you do not understand why you are still being charged $103. The Plan denied your request. The Plan says this service 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 the bone replacement graft for ridge preservation provided on December 2, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.You asked the Plan to pre-approve SNF care. 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 must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mammography provided to the enrollee on December 30, 2019. You asked the Plan to pay for the mammography. The Plan denied your request. The Plan says the claim was billed with the incorrect place of service. The Plan must follow Medicare rules. Medicare rules say that for enrollees who are registered hospital inpatients or outpatients, the inpatient or outpatient hospital POS code must be reported. We looked at the file and Medicare rules. The services were billed with an inpatient place of service code. The records show that the services were provided in an outpatient setting. An inpatient place of service code is inappropriate for outpatient services. Based on this information, we decided that Medicare rules for coverage of the mammography have not been met. Therefore, we decided that the Plan does not have to pay for the mammography provided to the enrollee on December 30, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) rendered by an out of network (OON) provider on October 23, 2019. You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment as the services provided were medically necessary. The Plan denied your request. The Plan says that the services were rendered by an out of network provider, without prior authorization. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care .The provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services 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 the subsequent nursing facility care (99308) rendered by the out of network (OON) provider on October 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periodontal maintenance (D4910) provided on December 4, 2019. You asked the Plan to reimburse you for the periodontal maintenance. You say that the plan did not reimburse you for the oral exam and bitewings. You say that you paid $51 for these services despite the 2019 Enrollment guide saying there is a $0 copayment. The Plan denied your request. The Plan says periodontal maintenance is not listed as a covered 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. Though the Plan offers a dental benefit in excess of Medicare coverage, periodontal maintenance is not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the periodontal maintenance (D4910) provided on December 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist visit provided on November 21, 2019. You asked the Plan to waive the copayment for the specialist visit. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received services provided by a specialist on November 21, 2019. The Plan states the correct copayment has applied per your contract with the Plan.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 specialist services. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received services provided by a specialist on November 21, 2019. You have been asked to pay a $20 copayment for the specialist visit, which is less than the $35 contracted amount. The specialist visit falls within the Physician/Practitioner 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 specialist visit provided on November 21, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the sacroiliac (SI) joint, with image guidance (64625). You asked the Plan to pre-approve radiofrequency ablation, nerves innervating the SI joint, with image guidance. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 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 radiofrequency ablation, nerves innervating the SI joint, with image guidance. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found SI joint ablation 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 radiofrequency ablation, nerves innervating the SI joint, with image guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the sacroiliac (SI) joint, with image guidance (64625).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental drugs for home use. You asked the Plan to pre-approve the drugs. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered 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. Additionally, your dental plan does not cover these drugs. Therefore, we decided that the Plan does not have to pre-approve dental drugs for home use.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve saline. You asked the Plan to pre-approve saline. You say that you need saline for your wound. The Plan denied your request. The Plan says saline is not covered by Medicare or the Plan. The Plan must follow Medicare rules. Medicare rules say that claims for products that are not able to be used as a primary or secondary dressing on a qualifying wound of the skin or that are composed of materials that do not serve a therapeutic or protective function will be denied as statutorily non-covered, no benefit. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of saline have not been met. Therefore, we decided that the Plan does not have to pre-approve saline.