Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Partially Favorable

We decided that the Plan has to pre-approve Decitabine. We decided that the Plan does not have to pre-approve Ondansetron.
You asked the Plan to pre-approve Decitabine. You say that this is medically necessary. The Plan says that this drug regimen is not supported to treat relapse/refractory t-cell acute lymphoblastic leukemia.
We decided that the Plan has to pre-approve Decitabine.
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 for Decitabine. Our reviewer says that this drug is medically reasonable and necessary. Our physician reviewer found that Drug-Dex has a reference for the use of Decitabine in the treatment of t-cell acute lymphoblastic leukemia. The strength of evidence is strong, and meets the CMS rules for medically-accepted use. Therefore the use of Decitabine is medically reasonable and necessary to treat the enrollee and the documentation supports that it will be safe and effective for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Decitabine have been met. Therefore, we decided that the Plan has to pre-approve Decitabine.
We also decided that the Plan does not have to pre-approve Ondansetron.
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 for Ondansetron. Our reviewer says that this requested drug is not medically reasonable and necessary. Our physician reviewer found that the use of Ondansetron is
only indicated for highly or moderately emetic chemotherapy and can be given orally with parenteral low emetic risk anti-cancer drugs. The NCCN Guidelines Version 2.2020 Antiemesis, page AE-3 lists Decitabine as minimal emetic risk. The submitted records do not indicate special needs for this enrollee to have Ondansetron. The documentation does not support the use of Ondansetron as medically reasonable and necessary nor that it is safe and effective for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ondansetron have not been met. Therefore, we decided that the Plan does not have to pre-approve Ondansetron.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on May 29, 2019, August 19, 2019 and October 18, 2019.You asked the Plan to pay for the psychotherapy services.The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 servicesat 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 psychotherapy services provided on May 29, 2019, August 19, 2019 and October 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea porcelain/ceramic crown for tooth #19.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis request exceeds the maximum allowed limit in the subscriber agreement.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 crowns once every five years.This same procedure was received for the same tooth on September 28, 2018. 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 Plandoes not haveto pre-approvea porcelain/ceramic crown for tooth #19.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient mental health services (90839, 90840) provided October 18 to December 17, 2018.You asked the Plan to pre-approve the outpatient mental health services.. You say that the services were medically necessary.The Plan denied your request. The Plan says services provided by this type of provider are not eligible for coverage.The Plan must follow Medicare rules. Medicare rules say that Licensed Marriage and Family Therapists are not eligible to participate in the Medicare program. We looked at the file and Medicare rules. The services were rendered by a Licensed Marriage and Family Therapist. Based on this information, we decided that Medicare rules for coverage of the outpatient mental health services. have not been met.Therefore, we decided that the Plan does not have to pre-approve outpatient mental health services (90839, 90840) provided October 18 to December 17, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered on December 18, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not separately payable.The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility.Therefore, we decided that the Plan does not have to pay for the special pump services rendered on December 18, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided on December 5, 2019.You asked the Plan to pay fora lumbar-sacral orthosis. You say that this should be covered.The Plan denied your request. The Plan says the documentation submitted did not include an itemized shipping invoice.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. Although the file contains a delivery slip, there is no itemized billing or shipping invoice with the carrier's tracking number to corroborate the specific item was delivered.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided on December 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forreplacement frames (V2020) and lenses (V2784).You asked the Plan to pay forthe vision services. You say that you had lost your glasses and was under the impression you could receive frames yearly.The Plan denied your request. The Plan says this request exceeds the benefit frequency limit.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 these services when this is only covered once every 2 years.We looked at the file and the Plan's rules. The eyewear benefit is covered once every 2 years and there is no coverage for replacing lost eyewear. Based on this information, we decided that the Plan's rulesfor coverage of the vision services have not been met.Therefore, we decided that the Plan does not have to pay forreplacement frames (V2020) and lenses (V2784).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical alert device (A9280).You asked the Plan to pre-approvethe medical alert device. You say that you are appealing the denial because you live alone and have heart conditions.The Plan denied your request. The Plan says this is considered emergency communication systems and is therefore not covered.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 pre-approvethe medical alert device (A9280).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe annual physical exam you received on November 26, 2019.You asked the Plan to pay forthe exam. The Plandenied your request. The Plan says this exam is only covered once per year.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 $0 copayment for one annual physical exam per calendar year. Review of the file shows that you had a physical exam on November 26, 2019. The records also show that you had a covered annual physical exam on September 23, 2019. The plan only covers this service once per calendar year. This means that the exam in question exceeds the benefit limit. This means that you have been asked to pay the correct amount based on your contract with the Plan.Therefore, we decided that the Plan does not have to pay forthe annual physical exam you received on November 26, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient hospital services rendered to
you on December 6, 2019.
You asked the Plan to waive the coinsurance for these services. You say that you disagree with the charges.
The Plan denied your request. The Plan says the coinsurance was 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 Plan clearly says that you must pay a 20%
coinsurance for out-of-network outpatient hospital services.
Review of the file shows that you received outpatient hospital services on December 6, 2019. You have been
asked to pay a 20% coinsurance for these services. These services fall within the out-of-network outpatient
hospital 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 coinsurance for the outpatient
hospital services rendered to you on December 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine foot care rendered on January 3, 2020.You asked the Plan to pay for these services. You say that you had a sore for two weeks and were advised to see this provider.The Plan denied your request. The Plan says routine foot care is not covered.The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or feet or have fungal nails. Records do not show that any of these conditions are present. The services you are asking the Plan to pay for are routine foot care services. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the routine foot care rendered on January 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the neck spine (72141).You asked the Plan to pre-approve an MRI of the neck spine. You say that the service is 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. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare coverage criteria have been met.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the neck spine have not been met. Specifically, medical records were not provided. Without this documentation, medical necessity is not able to be established.Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the neck spine(72141).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist visit provided on February 21, 2020.
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 in a specialist's office on the date of service at issue in this appeal. The Plan says 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 $15 copayment for each specialist visit for Medicare-covered services. We looked at the file, the Plan's contract and Medicare rules. The file shows you received services provided in a specialist's office on February 21, 2020. You have been asked to pay a $15 copayment for the specialist visit. 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 February 21, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) rendered.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the enrollee was on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) rendered.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for automatic external defibrillator, with integrated electrocardiogram analysis, garment type (K0606) provided to the enrollee on November 16, 2019.You asked the Plan to pay for the DME. You say that the claim should be paid.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. K0606 was denied because the patient was in an inpatient status, per CMS Policy, and was not separately reimbursed because it was included in the facility reimbursement. The DME provider is billing this code for November 16, 2019 and per the members claim history, the member was also inpatient from November 13, 2019 through December 7, 2019. DME is for items a member is using in his or her home. CMS does not make separate payment for DMEPOS for a member in an inpatient institution. The institution is expected to provide all medically necessary DMEPOS items during a member's stay.Therefore, we decided that the Plan does not have to pay for automatic external defibrillator, with integrated electrocardiogram analysis, garment type (K0606) provided to the enrollee on November 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forfoot orthotics.You asked the Plan to pay forfoot orthotics. You say that at your initial exam with your Doctor it was established that the orthotics were medically necessary. You say that your Doctor's office contacted the Plan and were told that the orthotics were ninety percent covered. You stated that because of this information you agreed to get the orthotics. You say that since the orthotics are medically necessary and you were misinformed, you believe that the Plan should provide coverage for the orthotics.The Plan denied your request. The Plan says this item is nota covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have topay forfoot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for tissue graft for tooth surgery (D4277) provided July 24, 2019.You asked the Plan to pay for the vision services. You say that you were told you would get a check and feels that you are entitled to the reimbursement. You were not able to brush your teeth because it was very sensitive.The Plan denied your request. The Plan says this service is not covered under the plan benefits. Enrollee's must receive their dental services from an in-network provider.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 tissue graft for tooth surgery (D4277) provided July 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the physician services provided on
December 3, 2019.
You asked the Plan to waive the deductible for the physician 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 physician services on the date of service at issue in this appeal. The
Plan says that the correct amount has applied towards your deductible per your contract with the Plan.
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 $183 deductible for Doctor Visits.
The item or service you asked the Plan to waive the deductible for falls within the benefit category Doctor
Visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $183
deductible for Doctor Visits. This cost sharing is a contractual obligation that had not been met at the time the
physician services were received on December 3, 2019. Therefore, we decided that the Plan does not have to
waive the deductible for the physician services provided on December 3, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services providedon December 3, 2019 and December 10, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 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 physician's services providedon December 3, 2019 and December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care provided on November 19, 2019 by an out of network (OON) provider.You asked the Plan to pay for wound care. You say that these services are provided in good faith. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-network.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 November 19, 2019 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 vaccine provided to by an out-of-network provider on November 8, 2019.You asked the Plan to pay for the vaccine. You say that this has always been paid.The Plan denied your request. The Plan says out-of-network services are 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 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 vaccine provided to by an out-of-network provider on November 8, 2019.