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

We decided that the Plan does not have to pre-approve Opdivo (Nivolumab).
You asked the Plan to pre-approve the Opdivo (Nivolumab). You say that the enrollee does have recurrent disease and therefore has an indication of use for Opdivo. The Plan denied your request. The Plan says the enrollee's use of Opdivo is not considered a medically accepted indication.
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 Opdivo. Our reviewer says that the Nivolumab is not medically necessary. Our physician reviewer found the enrollee has had improvement of her cancer based on the computed tomography imaging dated April 16, 2020. Therefore, she does not have progression of the cancer. Our reviewer found that the drug is not FDA approved for maintenance therapy in the enrollee's situation. Our reviewer also found that the drug is not supported for maintenance therapy in this clinical setting in any of the CMS approved compendia. 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 Opdivo (Nivolumab) have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo (Nivolumab).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 6, 7, 8, 9, 10, 11, and 12.
You asked the Plan to pre-approve the crowns. The Plan denied your request. The Plan says the service is not necessary due to the lack of information.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the crowns when the services are medically necessary and reasonable. 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 crowns. Our reviewer says that the crowns are not medically necessary. Our physician reviewer found the supplied photos show some gingival recession on the facials of tooth #'s 8 and 9. The clinical notes state there is metal showing on the margins of the crowns and there is recurrent decay at the margins of #8 and #9. The photos and x-rays do not show recurrent decay where the provider had indicated, with the photos showing areas of recession only. The recessed areas on #8 and #9 are not clearly seen to be carious and the supplied x-rays do not support this contention. Our reviewer found that the exposed metal margins are not defective and are part of the structure of porcelain-metal crowns which become visible when there is marginal recession of the gingiva. Our physician reviewer also found that given there are no significantly defective crowns evident (only #8 and #9 were claimed to have poor margins), there is currently no medical necessity for replacement crowns. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 6, 7, 8, 9, 10, 11, and 12.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection, expandable controller, expandable controller harness, transfer handles, power seat elevation feature and functional reach package for the enrollee.
You asked the Plan to pre-approve these services. You say that these items are medically necessary. The Plan denied your request. The Plan says that the enrollee's strength and function are adequate for him to control the power options using their own switches.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code K0108 is wheelchair component or accessory, not otherwise specified. We find that CPT code K0108 (transfer handles) is not supported in the medical record. Specifically transfer handles are more appropriately coded at E0705 (Transfer device, any type). Based on this information, we decided that Medicare rules for coverage of transfer handles has not been met. Therefore, we decided that the Plan does not have to pre-approve transfer handles for the enrollee.
Medicare rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature. The file indicates that the functional reach package is attached to the power seat elevation feature. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature or functional reach package for the enrollee. 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 these services. Our reviewer says that the electronic connection, expandable controller and expandable controller harness are not considered medically reasonable and necessary in this case. The documentation notes that the plan approved a Group 3 power wheelchair. The patient does not require the E2311 controller as the patient's upper limb strength and function is sufficient for the patient to operate the controls with their own switches/buttons. There is not a need to control the power options with a joystick, sip and puff or other non-proportional device, or to operate 3 or more actuators through the drive control. The patient does not require a separate display, an attendant control and other electronic devices. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of the electronic connection, expandable controller and expandable controller harness. We looked at this physician's review, the file, and Medicare rules. 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 pre-approve an electronic connection, expandable controller or expandable controller harness for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient mental health care provided on January 31, 2020.
You asked the Plan to waive the copayment for outpatient mental health care. You say that you cannot afford the increase in charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for outpatient mental health care. You have been asked to pay a $40 copayment for outpatient mental health care. Outpatient mental health care falls within the outpatient mental health 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 outpatient mental health care provided on January 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visits provided on December 6, 2019 and December 31, 2019.You asked the Plan to waive the copayment forthe office visits. You say that the provider is in-network. You say that the copayment should be removed.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 $40 copayment for Medicare covered podiatry services at an in-network specialist's office.You have been asked to pay a $40 copayment for each office visit. The total amount you owe is $80 ($40/visit x 2 visits = $80). The office visits fall within the "Podiatry 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 agreedto pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe office visits provided on December 6, 2019 and December 31, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 3, 2019 through April 4, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 3, 2019 through April 4, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from October 2, 2019 to October 30, 2019.You asked the Plan to pay for home health 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 as billed.The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the submitted claim does not include the required FIPS code.Therefore, we decided that the Plan does not have to pay forthe home health services provided to the enrollee from October 2, 2019 to October 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete lower denture (D5120).
You asked the Plan to pre-approve the dental services. You say that you received a denture and partial more than 5 years ago. The Plan denied your request. The Plan says this request exceeds the benefit frequency limit.
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. This service is limited to once every 5 years. Records show that a full lower arch denture was provided 9/05/2017. 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 pre-approve a complete lower denture (D5120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from October 25, 2019 through October 30, 2019 provided by an in-network provider.You asked the Plan to waive the copayment for inpatient hospital care. You say that your previous hospital stays at this hospital had lesser or no copayment.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). You received five (5) days of inpatient hospital care from an in-network acute care hospital from October 25, 2019 through October 29, 2019. You are responsible for $325 copayment per day for days 1-5. According to your plan benefit, you should be responsible for $1625, based on your plan benefit: $325 per day x 5 days = $1625. However, the Health Plan has reduced the cost share and only assessed you: $325 per day x 4 days = $1300. The Health Plan has processed the claim for a lower copayment than stated in the plan benefit and is not seeking to assess the full copayment of $1625. 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 inpatient hospital care from October 25, 2019 through October 30, 2019 provided by an in-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the intermittent compression device
You asked the Plan to pay for the intermittent compression device. You say that the claim should be paid. The Plan denied your request. The Plan says documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery.
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. The documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery. Therefore, we decided that the Plan does not have to pay for the intermittent compression device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of ferric carboxymaltose.
You asked the Plan to pre-approve ferric carboxymaltose. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the enrollee's potential difficulty with iron absorption is well compensated with blood counts in the normal range.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve ferric carboxymaltose. Our reviewer says that the enrollee does not meet the Medicare criteria for use of ferric carboxymaltose. Our physician reviewer found documentation notes that the enrollee is taking daily oral ferrous sulfate and is noted to have normal hemoglobin and hematocrit levels. Therefore, medical records to not support the necessity of the requested medication. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ferric carboxymaltose have not been met. Therefore, we decided that the Plan does not have to pre-approve use of ferric carboxymaltose.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that the stockings should be covered because there is a qualifying wound. The Plan denied your request. The Plan says are noncovered because they do not meet the statutory definition of a dressing.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the periodontal scaling and root planing (D4342).You asked the Plan to pre-approvethe scaling and planing. You say that this service will help prolong the longevity of the enrollee's teeth.The Plan denied your request. The Plan says this service is not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve the periodontal scaling and root planing (D4342).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe cataract surgery and the Part B injection provided on October 22, 2019.You asked the Plan to waive the cost share for the cataract surgery and the Part B injection. You say that you should not be billed for the services withoutpermission. The Plan denied your request. The Plan says you have been charged 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 $75 copayment for surgery services at an in-network ambulatory surgical center and 20% coinsurance for in-network Medicare Part B covered drugs. You have been asked to pay a $75copayment for the cataract surgery and $89.88 which is 20% of the allowed amount for the Part B injection. The allowed amount is $449.40. ($449.40 x 20% = $89.88). ($75 + $89.88 = $164.88). The cataract surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Part B injection falls within the "Medicare Part B prescription drugs" benefit category.This means that you have been asked to pay the correct the 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 cost share forthe cataract surgery and the Part B injection provided on October 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea crown (D2740) for tooth #3.You asked the Plan to pre-approvethe crown. You say that a new buildup was not installed under the last crown on tooth #3 which caused the crown to break off of your tooth. You also say that there is decay present on the tooth and if left untreated any longer, it will cause a medical infection.The Plan denied your request. The Plan says the service exceeds the frequency limitation in your benefit 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, crowns, inlays, and onlays and are limited to one procedure per tooth every five plan years. The record shows that you received a crown (D2740) on tooth #3 on May 30, 2018, and your crowns, inlays, and onlays benefit for tooth #3 has been exhausted.Therefore, we decided that the Plan does not have to pre-approvea crown (D2740) for tooth #3.Your complaint about your experience with the initial treating provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve $3,700 for dental implants to be provided by an out-of-network provider.
You asked the Plan to pre-approve the dental implants. You say that you received a root canal that caused an infection and as a result you had surgery to remove your teeth. You also say that you went to a new provider who recommended dental implants to improve your quality of life. The Plan denied your request. The Plan says you can spend up to $2,300 in covered dental services provided within the network. The Plan also says that receiving dental services from an out-of-network provider are not a covered benefit. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, you have a $2,300 annual maximum benefit, and the requested items or services are not covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pre-approve $3,700 for dental implants to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided by provider from November 15, 2019 to December 11, 2019.You asked the Plan to pay for chiropractic services. You say that you are appealing with records.The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services are not covered by Medicare or the Plan when performed by a chiropractor.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The rules say that chiropractic services are only covered by Medicare when billed with certain specific diagnosis codes.The records show that the service at issue is not manual manipulation of the spine.Additionally, these services were provided for diagnoses that are non-covered by Medicare and the Plan. Therefore, we decided that the Plan does not have to pay for chiropractic services provided by provider from November 15, 2019 to December 11, 2019.