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

We decided that the Plan does not have to pay forgingival irrigation -per quadrant (D4921), local anesthesia in conjunction with operative or surgical procedures (D9215), periodontal scaling and root planing -four or more teeth per quadrant (D4341), oral hygiene instructions  (D1330) and drugs or medicaments dispensed in the office for home use (D9630) provided on December 16, 2019.You asked the Plan to pay forthe dental services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says the services are not a covered benefit under the plan.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. The services are not listed in your EOC as a covered benefit; therefore, the services are not covered.Therefore, we decided that the Plan does not have to pay forgingival irrigation -per quadrant (D4921), local anesthesia in conjunction with operative or surgical procedures (D9215), periodontal scaling and root planing -four or more teeth per quadrant (D4341), oral hygiene instructions  (D1330) and drugs or medicaments dispensed in the office for home use (D9630) provided on December 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the walk-in air and whirlpool jetted tub (E1399) and sales tax (S9999).
You asked the Plan to pay for the tub and sales tax. You say that you've had 4 back surgeries and no feeling in your right leg. You cannot get in a regular tub and you don't have the money and is requesting help to pay for the walk in tub. The Plan denied your request. The Plan says this is a convenience and personal hygiene item and is not covered by Medicare. Medicare does not pay for S code items.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for the walk-in air and whirlpool jetted tub (E1399) and sales tax (S9999).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the wheelchair ramp purchased on November 14, 2019.
You asked the Plan to reimburse you for the wheelchair ramp. You say that you cannot get out of your house without the wheelchair ramp. The Plan denied your request. The Plan says wheelchair ramps are excluded from coverage as they are not considered reasonable and necessary.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Medicare does not cover home modifications. Also, the item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to reimburse you for the wheelchair ramp purchased on November 14, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services provided by an out of network (OON) provider.
You asked the Plan to pay for the podiatry services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services received were neither emergent nor urgent and prior authorization was not obtained to seek out-of-network care.
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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the podiatry services provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forresin-based composite -one surface, posterior (D2391) and resin-based composite -three surfaces, posterior (D2393) providedon January 9, 2020.You asked the Plan to pay forthe dental services. You say that you had to have these services done to make sure that they won't create an infection for surgery.The Plan denied your request. The Plan says the services are nota covered benefit under the plan.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. The services are not listed in your EOC as a covered benefit; therefore, the services are not covered.Therefore, we decided that the Plan does not have to pay forresin-based composite -one surface, posterior (D2391) and resin-based composite -three surfaces, posterior (D2393) provided on January 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the physician services
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve drug regimen Pertuzumab, Trastuzumab, Docetaxel, and Cyclophosphamide.You asked the Plan to pre-approve the requested drugs. The Plan denied your request. The Plan says there is no supportive data to show this line of treatment improves outcomes.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 requested drugs. Our physician reviewer found that the enrollee has progressive metastatic breast cancer, who has received previous Pertuzumab and had progression of the cancer on that treatment. The only primary medical record submitted for review was a PET scan. A summary of a progress note was included. The actual progress note was not submitted for review. The requested combination is not FDA approved for the requested use. The requested use is not supported in any of the CMS approved compendia. NCCN guidelines state patients previously treated with chemotherapy plus Trastuzumab in the absence of Pertuzumab in the metastatic setting may be considered for one line of therapy including both Trastuzumab plus Pertuzumab in combination with or without cytotoxic therapy (such as Vinorelbine or Taxane.) This indicates that continuation of Pertuzumab after progression on that drug is not recommended. Therefore, the requested drug combination is not 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 the requested drugs have not been met. Therefore, we decided that the Plan does not have to pre-approve drug regimen Pertuzumab, Trastuzumab, Docetaxel, and Cyclophosphamide.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on January 7, 2020.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plandid not pre-approve the laboratory services.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 laboratory services provided on January 7, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Magnetic Resonance Imaging (MRI) of the Brain (70551) provided January 13, 2020.You asked the Plan to waive the copayment for the MRI. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct cost sharing was applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for Outpatient Diagnostic Tests. You have been asked to pay a $150 copayment for the MRI. The MRI falls within the Outpatient Diagnostic Tests 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 Magnetic Resonance Imaging (MRI) of the Brain (70551) provided January 13, 2020
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe outpatient mental health services (90837) provided on September 9, 2019 to January 29, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe outpatient mental health services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not emergent or preauthorized. There were network providers available.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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore,we decided that the Plan does not have to pay forthe outpatient mental health services (90837) provided on September 9, 2019 to January 29, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergent transportation (A0428, A0382 and A0425) provided.
You asked the Plan to pay for the non-emergent transportation. You say that you would like reconsideration because these services were medically necessary. The Plan denied your request. The Plan says non-emergency ambulance transportation is not a covered benefit under Medicare.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We looked at your request, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the non-emergent transportation have not been met. Specifically, the record indicates that this transportation was a means to transfer the member from a party to their nursing facility. Transportation services could have been provided at a lower level of care. Therefore, we decided that the Plan does not have to pay for non-emergent transportation (A0428, A0382 and A0425) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe physician services provided on May 7, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe physician services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.Medicare rules say that plans can require enrollees to get care from network providers. The contract withthe 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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe physician services provided on May 7, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe immunotherapy injections provided on December 30, 2019.You asked the Plan to waive the copayment forthe immunotherapy injections. You say that the injections were administered by the nurses. You say that there is no copayment listed for allergy injections in your plan.The Plandenied your request. The Plan says the copayment 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 Planclearly says that you must pay $50 for each specialist visit for Medicare-covered benefits. You have been asked to pay a $50 copayment for the immunotherapy injections. The immunotherapy injections fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The immunotherapy injections are considered a physician service. 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 immunotherapy injections provided on December 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on October 24, 2019.You asked the Plan to pay forthe laboratory services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed priorto services taking place.Therefore, we decided that the Plan does not have to pay forthe laboratory services provided on October 24, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Emergency Room Services provided October 25, 2019.
You asked the Plan to waive the copayment for the Emergency Room Services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost-sharing was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for Emergency Care. You have been asked to pay a $100 copayment for the Emergency Room Services. The Emergency Room Services falls within the Emergency Care 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 Emergency Room Services provided October 25, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Skilled Nursing Facility (SNF) services.

You asked the Plan to waive the copayment for the SNF services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost sharing was applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $172 per day copayment for days 21 through 100 for Skilled Nursing Services. 

You have been asked to pay a $172 per day copayment for the SNF services. 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 Skilled Nursing Facility (SNF) services provided.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Diazepam provided on November 11, 2019.
You asked the Plan to pay for the Diazepam. You say that this drug was administered in the hospital because they did not have the liquid injectable on site. You also say that you had no control over what drugs were given. The Plan denied your request. The Plan says this drug is a self-administered drug. The Plan also says this drug is not covered under 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 pay for the Diazepam provided on November 11, 2019.
Benefits for the Diazepam 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 Euflexxa.
You asked the Plan to pre-approve Euflexxa. You say that the enrollee wants the injections. The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or intolerance to Monovisc and Orthovisc.
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 Euflexxa. Our reviewer says that criteria is not met. Our physician reviewer found there is no documentation of trial and failure of Monovisc and Orthovisc. The documentation does not support that Monovisc and Orthovisc would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 25, 2019.You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place.Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 25, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs.
You asked the Plan to pay for the self-administered drugs. You say that you were given the drugs because pharmacies were closed on the date of service due to the Christmas holiday. The Plan denied your request. The Plan says Coverage may be available under the Part D prescription drug benefit, however coverage for self-administered drugs provided in the outpatient setting is not available 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 pay for self-administered drugs.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.