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

We decided that the Plan does not have to pay for BRCA screening testing provided to the enrollee on March 
11, 2020. 
 
You asked the Plan to pay for the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare says screening services with no relation to a medical diagnosis of disease for 
the health of the patient are not a 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 test at issue in this appeal, the testing, was requested solely for screening purposes. There is no personal 
history of cancer. Medicare does not cover this test solely for screening purposes. Therefore, we decided that 
the Plan does not have to pay for BRCA screening testing provided to the enrollee on March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 2, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the medical services. You say that these services were medically necessary. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.
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 medical services provided on July 2, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 2, 2020, by an OON 
provider. 
 
You asked the Plan to pay for skilled nursing facility discharge management. You say that these services were 
necessary. The Plan denied your request. The Plan says these services were provided with no 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 requested provider in this case is not a network provider with the Plan. 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 medical services provided on June 2, 2020, by 
an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for outpatient surgery services provided on 
August 6, 2019. 
 
You asked the Plan to waive the cost share for outpatient surgery services. You say that she thought that she 
could go anywhere to receive 100% coverage because she had a PPO. You say that she was unaware the 
surgery would accrue these out-of-pocket fees. The Plan denied your request. The Plan says the cost share 
applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. The 
enrollee's contract with the Plan says that the deductible is $750. This is the amount you have to pay out-of-
pocket before we will pay our share for your covered medical services. Until you have paid the deductible 
amount, you must pay the full cost for most of your covered services. The contract says that after the deductible 
is paid, the enrollee must pay 40% coinsurance for out-of-network outpatient surgery, physician services and 
laboratory services.  
 
The item or service you asked the Plan to waive the cost for falls within the "Outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan 
has followed Medicare rules by clearly disclosing in the contract that the $750 deductible applies to out-of-
network services. This cost sharing is a contractual obligation that had not been met at the time outpatient 
surgery services were received on August 6, 2019. Therefore, $506.89 has been applied to meet the deductible. 
 
Since the $750 deductible was met, the enrollee has also been asked to pay $4,436.01. 
 
Service Allowed Amount Coinsurance Member Liability 
Corneal Transplant-Facility Fee $837.35 40% $334.94 
Corneal Transplant-Physician Fee $4,590.15 40% $1,836.06 
Anesthesia $133.27 40% $53.30 
Corneal Tissue Processing $5,502.63 40% $2,201.05 
Pathology $13.71 40% $5.48 
Tissue Exam $12.95  $5.18 
TOTAL:  40% $4,436.01 
 
The corneal transplant facility services fall within the Outpatient surgery, including services provided at 
hospital outpatient facilities and ambulatory surgical centers benefit category. The corneal transplant 
physician services and anesthesia fall within the Physician/Practitioner services, including doctor's office 
visits benefit category. The pathology and tissue exam fall within the Outpatient diagnostic tests and 
therapeutic services and supplies benefit category. 
 
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This 
cost sharing is a contractual obligation the enrollee agreed to pay when enrolling in the Plan. Therefore, we 
decided that the Plan does not have to waive the cost share for outpatient surgery services provided on August 
6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed and a manual wheelchair. 
 
You asked the Plan to pre-approve the items. You say that there is no evidence that this denial is valid. The 
Plan denied your request. The Plan says the Medicare coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that a manual wheelchair will be covered when there is a 
significant mobility limitation that cannot be resolved with a cane and/or walker, and the wheelchair will 
significantly improve the enrollee's ability to participate in MRADLs.  
 
The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position.  
 
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 items. Our reviewer says that the 
requested items are not medically reasonable or necessary.  
 
Our physician reviewer found that based on the medical records provided, there is no documentation your 
condition requires positioning of the body in ways not feasible in an ordinary bed, frequent changes in body 
position or immediate changes in body position. There is no documentation that your condition requires special 
attachments that cannot be fixed and used on an ordinary bed. There is no documentation that the requested bed 
is medically necessary for you. 
 
Our physician reviewer found based on the medical records provided, it is not clear that you have a mobility 
limitation that significantly impairs the ability to complete mobility-related activities of daily living 
(MRADLs). It is not clear that your mobility deficit cannot be resolved by a cane or walker. There is no 
documentation that the enrollee's home is appropriate for the wheelchair; there is a statement for the equipment 
vendor to this effect but not from the equipment prescriber. It is not clear that the wheelchair will significantly 
improve your ability complete MRADLs. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a semi-electric hospital bed and a manual wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on April 7, 2020, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for wound care. You say that you would like this claim reprocessed and approved 
for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says 
that the member's primary care physician did not refer 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 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 wound care provided on April 7, 2020, by an out-
of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent. 
 
You asked the Plan to pre-approve Dupixent. The Plan denied your request. The Plan says the enrollee's 
medical plan does not cover outpatient prescription drugs. 
 
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 Dupixent.  
 
Benefits for Dupixent may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waivethe cost share charged forMedicare Part B drugs and radiation provided from July 13, 2020, to August 21, 2020.You asked the Plan to waivethis cost share. You say that you are on a fixed income and cannot afford these copayments.The Plan denied your request. The Plan saysthis cost share is a contractual obligation. 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 cost share for Medicare Part B drugs and radiation treatments. 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 towaivethe copayments charged for Medicare Part B drugs and radiation services provided from July 13, 2020, to August 21, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
September 7, 2019. 
 
You asked the Plan to waive the copayment for the emergency room services. 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 emergency room services on the date of service at issue in this 
appeal. The Plan says that 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 $85 
copayment for Emergency care.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received emergency room 
services on September 7, 2019. You have been asked to pay a $85 copayment for the emergency room services. 
The emergency room services fall 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 the emergency room services provided on September 7, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services with CPT code G0483 provided on April 27, 
2020. 
 
You asked the Plan to pay for CPT code G0483. 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 providers must report services correctly.  
 
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code 
per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services with CPT code G0483 provided on April 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. 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 LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical x-ray with dental code D0220 provided on 
August 27, 2020. 
 
You asked the Plan to pay for dental code D0220. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says dental code D0220 is limited to two procedures 
per calendar year. The Plan says you reached your limit for this dental code for the calendar year as of January 
16, 2020. 
 
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, dental code D0220 is limited to two 
per calendar year. The file shows that you reached your limit for dental code D0220 as of January 16, 2020. 
Therefore, we decided that the Plan does not have to pay for the periapical x-ray with dental code D0220 
provided on August 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not require an intensive, complex, multidisciplinary approach to daily therapy.
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 physician reviewer found that the enrollee was admitted to the acute hospital for sepsis and a urinary tract infection. Her medical conditions are stable. The complexity of her nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe supply allowance provided on August 30, 2020.You asked the Plan to pay forthe supply allowance for therapeutic continuous glucose monitor (K0553). You say that the Plan should pay this claim.The Plan denied your request. The Plan says a physician order and medical records supporting the need for the supply allowance were requested but not received.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.We looked at the file and Medicare rules. The physician order and documentation supporting medical necessity is not in the case file.Based on this information, we decided that Medicare rules for coverage of the supply allowance for therapeutic continuous glucose monitor (K0553) have not been met.Therefore, we decided that the Plan does not have to pay forthe supply allowance provided on August 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT).

You asked the Plan to pre-approve the PBRT. You say that the medical community accepts proton therapy for prostate cancer as the standard of care. You say that this is well supported by respected scientific literature.The Plan denied your request. The Plan says PBRT is not medically reasonable and necessary in this case. The Plan says that intensity modulated radiation therapy (IMRT) is the standard of care for radiation therapy of prostate cancer.

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 PBRT. Our reviewer says that PBRT isnot considered medically reasonable and necessary in this case. Our physician reviewer found while proton therapy is not an experimental therapy, any potential benefit or detriment of proton therapy over standard intensity modulated radiation therapy (IMRT) is an investigational question for intermediate to low risk prostate cancer. Other treatment approaches, such as IMRT and image guided radiation therapy (IGRT) are also highly effective and well tolerated. Thus, whether proton therapy affords a benefit over other standard approaches (IMRT/IGRT) for prostate cancer is an area of investigation and remains controversial. Particularly, with the use of the SpaceOAR hydrogel spacer, the risk of GI/rectal toxicity is low, since the rectum is pushed away from the prostate. Such, it is even more unlikely that there would be a potential benefit from proton therapy. There are no compelling data to suggest that proton therapy is superior to or more beneficial than IMRT/IGRT. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients.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 PBRT have not been met.Therefore, we decided that the Plan does not have to pre-approveproton beam radiation therapy (PBRT)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on December 26, 2019, by an out of network (OON) provider.You asked the Plan to pay forthe medical services. You say that these services were medically necessary and provided in good faith.The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.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 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 medical services provided on December 26, 2019, by an out of network (OON) provider.