Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health aide services (G0156) provided from August 24, 
2020 to August 28, 2020. 
 
You asked the Plan to pay for home health aide services. You say that this should be covered. The Plan denied 
your request. The Plan says records for this service have not been submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that the provider, supplier, or 
beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine 
whether payment is due and the amount of payment. 
 
In this case, the CPT Code Manual definition of code G0156 is services of home health/hospice aide in home 
health or hospice settings, each 15 minutes. 
 
We find that CPT code G0156 is not supported in the medical record. Specifically, the submitted medical 
records do not include documentation of home health services being performed. Based on this information, we 
decided that Medicare rules for coverage of home health aide services have not been met. Therefore, we 
decided that the Plan does not have to pay for home health aide services (G0156) provided from August 24, 
2020 to August 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enhertu. 
 
You asked the Plan to pre-approve Enhertu. You say that the requested Enhertu is medically necessary. The 
Plan denied your request. The Plan says the requested Enhertu is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Enhertu. Our reviewer says that the 
requested Enhertu is not medically necessary. Our physician reviewer found the enrollee is diagnosed with 
metastatic pancreatic cancer. The requested Enhertu is not FDA-approved for the enrollee's diagnosis. The use 
of Enhertu is not supported by one of the major drug compendia or by clinical research that appears in a CMS-
approved medical journal. There is limited data for gastric cancer but not in pancreatic cancer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Enhertu have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Enhertu.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the excision provided on October 9, 2020 
and tissue transfer provided on November 6, 2020.  
 
You asked the Plan to waive the copayment for the excision and tissue transfer. You say that you should not 
have to pay a physician fee for the day you are having surgery. The Plan denied your request. The Plan says the 
copayments 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 $45 
copayment for each specialist visit for Medicare-covered services. Covered services include medically-
necessary medical care or surgery services furnished in a physician's office, certified ambulatory surgical 
center, hospital outpatient department, or any other location. 
 
 
  
You have been asked to pay a $45 copayment for the excision and a $45 copayment for the tissue transfer. The 
excision and tissue transfer fall 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 for the excision provided on October 
9, 2020 and tissue transfer provided on November 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the prophylaxis 
(D1110), the panoramic x-ray (D0330), the localized delivery of antimicrobial agent (D4381 x 2) provided 
from September 9, 2019, to January 20, 2020. 
 
You asked the Plan to pay for the dental services. You say that you sent claims to the plan for multiple dates all 
together. You say that you were advised that claims for the dates of service in this case were not received. You 
say that you cannot believe this as the other claims were received. You also say that these services should be 
covered. The Plan denied your request. The Plan says the claim for date of service September 9, 2019, was 
received more than 12 months after the date of service. The Plan says that a claim for services must be received 
within 12 months of the date services were rendered. The Plan says that panoramic x-ray is not listed as a 
covered service. The Plan also says that localized delivery of antimicrobial agent is not listed as a covered 
service either. 
 
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. 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 record shows that a claim for the dental services you received on September 9, 2019 was not filed until 
October 26, 2020. This means that more than one calendar year from the date of service had passed before a 
claim was filed. Additionally, though the Plan offers a dental benefit in excess of Medicare coverage, the 
panoramic x-ray and localized delivery or antimicrobial agents are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the 
prophylaxis (D1110), the panoramic x-ray (D0330), the localized delivery of antimicrobial agent (D4381 x 2) 
provided from September 9, 2019, to January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections (J3490) provided August 17, 2020. 
 
You asked the Plan to pay for the injections. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 3 units of CPT code J3490 is not supported in the medical record. The medical record only 
supports 1 unit of CPT code J3490. Additionally, since the medication was administered through a pump, there 
is a more appropriate CPT code that can be billed for this service. Based on this information, we decided that 
Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not 
have to pay for injections (J3490) provided August 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hospital outpatient clinic visit provided 
on November 18, 2020. 
 
You asked the Plan to waive the copayment for the hospital outpatient clinic visit. You say that you should not 
have a $20 copayment for the facility charge. You say you paid your $30 specialist copayment at the time of 
service. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 
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 $20 
copayment for all other Medicare-covered outpatient hospital services.  
 
You have been asked to pay a $20 copayment for the hospital outpatient clinic visit. The hospital outpatient 
clinic visit falls within the 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 copayment for the hospital outpatient clinic visit provided on November 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 17, 2020. 
 
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 testing is not covered. 
 
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, a comprehensive metabolic panel, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the laboratory services rendered on September 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services.

You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 diagnostic radiology 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 diagnostic radiology services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided on October 19, 2020. 
 
You asked the Plan to pay for the hearing aids. You say that your sister received hearing aids from this place 
and was very happy with them. The Plan denied your request. The Plan says the hearing aids received are not 
covered under your plan. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.  
 
We looked at the file, and the Plan's rules. The Plan cover only covers brand-specific hearing aids. Based on 
this information, we decided that the Plan's rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for the hearing aids provided on October 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit (99213, 11043).

You asked the Plan to waive the copayment for the office visit. 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 $35 copayment for specialist visits.

You have been asked to pay a $35 copayment for the office visit. The office visit falls within the specialist 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 for an office visit (99213, 11043).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Congenital Diaphragmatic Hernia testing (81406), Ataxia Telangiectasia Mutated Gene testing (81408) and MyRisk testing (81479).

You asked the Plan to pay for the testing services. You say that this testing is medically necessary. The Plan denied your request. The Plan says this testing is not covered by Molecular Diagnostic Services Program or Medicare.

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 pay for the testing services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are no medical records to establish the medical reasonableness and necessity of the requested services.

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 testing services have not been met. Therefore, we decided that the Plan does not have to pay for Congenital Diaphragmatic Hernia testing (81406), Ataxia Telangiectasia Mutated Gene testing (81408) and MyRisk testing (81479).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial nursing facility care provided on August 31, 2020. 
 
You asked the Plan to pay for the initial nursing facility care. You say that the doctor did not know that they 
needed an authorization for the services. The Plan denied your request. The Plan says the Plan is secondary 
payer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has indicated to 
the provider that they must bill the primary insurance carrier first and then resubmit the claim to the Plan. As 
the secondary insurer, the Plan cannot be held responsible for the initial nursing facility care until the primary 
insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the 
initial nursing facility care provided on August 31, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found this enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee has no complex wound care or other skilled nursing need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. Skilled nursing or therapy services are not required on a daily basis or as a practical matter on an inpatient basis, in a skilled nursing facility setting. The enrollee's needs can be met in the current setting until they are ready for a discharge to home or a community setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular testing provided on October 25, 2020. 
 
You asked the Plan to pay for the testing services. You say that the testing was ordered as part of the enrollee's 
treatment plan. The Plan denied your request. The Plan says the testing was not ordered or approved by the 
ordering provider. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic laboratory tests must be ordered by 
the physician who is treating the beneficiary. 
 
We looked at the file and the rules. The records do not indicate the physician's intent for the testing to be 
performed. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the molecular testing provided on October 25, 
2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve the additional physical therapy. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the additional physical therapy is 
not reasonable and 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 to pre-approve the additional physical therapy. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found a home exercise program is reasonable at this point in 
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 additional physical therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the coinsurance for the contrast agent.

You asked the Plan to waive the coinsurance for the contrast agent. You say that you were told you would have a $150 copayment. You say that you weren't prepared for the higher cost. The Plan denied your request. The Plan says that the coinsurance 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 does not say in clear and accurate terms how much you should expect to pay for the contrast agent.

We looked at your contract with the Plan. We did not see where the contract says enrollees must pay 20% coinsurance for the contrast agent. The Plan fully paid for the nuclear medicine study and applied 20% coinsurance to the contrast agent. The contrast agent is considered a medical supply, not diagnostic imaging or a study. The Plan contract does not clearly say how much you should pay for medical supplies. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the coinsurance for the contrast agent.

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 to open the case again, we will send you a letter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a duplex scan of extremity veins provided on  
August 29, 2019. 
 
You asked the Plan to pay for the duplex scan of extremity veins. 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 an emergent 
situation that 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 
service 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 a duplex scan of extremity veins provided on August 29, 2019.