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

e decided that the Plan does not have to pay forhospital care (99222) provided on June 30, 2019.You asked the Plan to pay forhospital care. You say that these medically necessary services were provided to the enrollee in good faith.The Plan denied your request. The Plan says rules for payment have not been met.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 hospital care was not filed until August 24, 2020. 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 forhospital care (99222) provided on June 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the three extractions provided on September 8, 2020 by an OON provider.
You asked the Plan to pay for the extractions. You say that you went to this location because you were advised that they accepted your insurance plan. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits or provider eligibility.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the three extractions provided on September 8, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided
on July 21, 2020.
You asked the Plan to pay for the comprehensive periodontal evaluation (D0180). You say that you were
informed you did not owe anything when leaving the visit, but later got a bill for $67. You say the bill is a
hardship for you to pay. The Plan denied your request. The Plan says the 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
comprehensive periodontal evaluation (D0180) provided on July 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fordental services received from August 18, 2020 to August 31, 2020.You asked the Plan to pay forthe services. You say that the provider islisted as the second provider in the directory.The Plan denied your request. The Plan says the provider is not participating.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 services when the services are medically necessary and reasonable.We looked at the file and Medicare rules. The plan paid the provider $125 of the billed $347. As the provider is out-of-network, you are responsible for the difference. Based on this information, we decided that the Plan's rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay fordental services received from August 18, 2020 to August 31, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for asinus augmentation with bone or bone substitutes via a lateral open approach (D7951) and extraction, erupted tooth requiring removal of bone (D7210) provided on September 15, 2020.You asked the Plan to pay for oral surgery and tooth extraction. You say that the service was medically necessary.The Plan denied your request. The Plan says you have received your yearly $100 dental reimbursement for the 2020 calendar year.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. Specifically, you have exhausted your $100 reimbursement for supplemental dental services for the 2020 calendar year. This means you areresponsible for anything over $100.Therefore, we decided that the Plan does not have to pay for asinus augmentation with bone or bone substitutes via a lateral open approach (D7951) and extraction, erupted tooth requiring removal of bone (D7210) provided on September 15, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vectibix 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 an off-label request.

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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found Panitumumab (Vectibix) is FDA approved for the treatment of patients with wild-type RAS (defined as wild-type in both KRAS and NRAS as determined by an approved test) metastatic colorectal cancer (mCRC), either as first-line therapy in combination with FOLFOX (fluorouracil, leucovorin, and oxaliplatin) or as a single agent following disease progression after prior treatment with fluoropyrimidine-, oxaliplatin-, and irinotecan-containing chemotherapy. Off-label use for metastatic, KRAS wild-type (in combination with other chemotherapy agents). Compendia states limitations of use: Panitumumab is not indicated for the treatment of patients with RAS-mutant mCRC or for whom RAS mutation status is unknown. Unfortunately, this patient has a KRAS mutation in exon 2 which would make them ineligible for Vectibix. The service 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 the drug have not been met.Therefore, we decided that the Plan does not have to pre-approve Vectibix for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional nine (9) physical therapy visits.You asked the Plan to pre-approve the additional nine (9) physical therapy visits. The Plan denied your request. The Plan says the additional nine (9) physical therapy visits are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 topre-approve the additional nine (9) physical therapy visits. Our reviewer says that skilled services are not medically necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that based on the medical records provided there is no documentation that the requested therapy is generally accepted as specific and effective therapy for the enrollee's condition. Based on the available records the enrollee appears to have improved with therapy with good range of motion and strength. Further formal therapy at this point does not appear to be likely to achieve any significant improvement in the enrollee's symptoms or functional status. Further utilization of the home exercise program appears appropriate at this point.Based on the medical records provided there is no documentation that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist.Based on the medical records provided there is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.
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 additional nine (9)physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional nine (9) physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided on November 11, 2019.You asked the Plan to waive the copayment fora specialist visit. You say that you disagree with the charges because the provider did nothing to treat your condition.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 $40 copayment for specialist services.You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 fora specialist visit provided on November 11, 2019.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay forthe $45 copayment for the comprehensive eye exam. We decided that the Plan does not have to pay forthe $40 charge for the refraction. You asked the Plan to pay forthe vision care. You say that you should not have to pay.The Plan says that the claim was processed correctly according to your benefits and the services rendered.We decided that the Planhas to pay forthe $45 copayment for the comprehensive eye exam. The Plan follows Medicare rules. 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 does not say in clear and accurate terms how much you should expect to pay for comprehensive eye exams.The plan has not fully substantiated their denial. The case file indicates that a $45 copaymentis required for a comprehensive eye exam. The fragment of the Evidence of Coverage that was provided by the plan does not indicate a $45 copayment for any of the listed vision services. Therefore, you should not have to pay this copayment.Therefore, wedecided that the Plan has to pay forthe $45 copayment for the comprehensive eye exam. We also decided that the Plandoes not have to pay the $40 charge for the refraction.
The Plan follows Medicare rules. The rules say that Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact lenses for refractive error only.It is correct that refraction is not covered, so the $40 fee for the refraction is not payable by the plan and must be paid in full by you.Therefore, we decided that the Plan does not have to pay forthe $40 charge for the refraction.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 orif 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Epoetin Alfa.
You asked the Plan to pre-approve Epoetin Alfa. You say that the continuation of treatment using the requested drug is medically appropriate and supported. The Plan denied your request. The Plan says the clinical records do not support the medical necessity of the requested drug.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Epoetin Alfa. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the labs are incomplete, as there are no iron studies, and the documentation does not support that the requested drug is medically reasonable and necessary. Without proper iron studies, the safety and effectiveness of the requested drug is not supported. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Epoetin Alfa have not been met. Therefore, we decided that the Plan does not have to pre-approve Epoetin Alfa.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Tetanus vaccine provided on September 17, 2020.You asked the Plan to pay forthe Tetanus vaccine. You say that the vaccine was necessary and should be covered.The Plan denied your request. The Plan says you received the vaccine as a preventative measure.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tetanus 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 Tetanus vaccine.Therefore, we decided that the Plan does not have to pay forthe Tetanus vaccine provided on September 17, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay forambulance services provided to the enrollee on August 3, 2020.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says that the claim was not billed according to CMS guidelines.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of HCPCS code A0429 is "Ambulance service, basic life support, emergency transport (bls-emergency)."We asked our coding 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 pay for the services. Our reviewers says that the services at issue in this case were supported by the medical records. Our coding reviewer found the medical records provided validate the patient was pronounced dead after arrival but before the beneficiary was loaded onboard ambulance (before or after arrival at the point-of-pickup), which was represented on the claim with an appropriate QL modifier, therefore this claim has met Medicare criteria and is payable.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have been met.Therefore, we decided that the Plan has to pay forambulance services provided to the enrollee on August 3, 2020.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 toopen the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for portable oxygen equipment purchased on August 27, 2020.
You asked the Plan to pay for the portable oxygen equipment.. You say that you need the oxygen right away
and Rotech took over a week. You say that the provider could not supply a portable oxygen concentrator and
that is why you had to purchase the equipment from another provider. The Plan denied your request. The Plan
says only rented oxygen equipment is eligible for coverage.
The Plan must follow Medicare rules. Medicare rules say that purchased oxygen equipment is statutorily noncovered.
Therefore, we decided that the Plan does not have to pay for portable oxygen equipment purchased on
August 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Chantix starting month box.
You asked the Plan to pre-approve Chantix. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered for your condition by Medicare Part B.
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 Chantix starting month box.
Benefits for Chantix 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on August 31, 2020.You asked the Plan to pay forthe 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 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 forthe medical services provided to the enrollee by an out-of-network provider on August 31, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on February 25, 2020.
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you were not aware that you would owe coinsurance. 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 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug on February 25, 2020. The allowed amount is $1,905.50 and 20% of that is $381.10. You have been asked to pay the total coinsurance amount of $381.10 for a Medicare Part B drug. A Medicare Part B drug 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 coinsurance for a Medicare Part B drug provided on February 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 20, 2020.
You asked the Plan to pay for a limited oral evaluation. You say that the service was medically necessary. The Plan denied your request. The Plan says the 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. Specifically, the service received is not listed in the Plan's EOC, and therefore, is not considered a covered service. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation, prophylaxis, and preventive procedure provided on June 1, 2020 by an OON provider.You asked the Plan to pay forthe periodic oral evaluation, prophylaxis, and preventive procedure. You say that you do not believe the correct amount was paid for these services.The Plan denied your request. The Plan says the preventive procedure is not a covered benefit. The Plan also says that you received services from a non-participating provider, and they are allowed to bill the difference between the billed amount and allowed amount to you.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 unspecified preventive procedure is not among those covered under this benefit. The contract also says that you can get care from an out-of-network dental provider, but you may pay more. You are responsible for the difference between the billed amount and allowed amount for the covered services.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation, prophylaxis, and preventive procedure provided on June 1, 2020 by an OON provider.