Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a shingle vaccine provided on November 23, 2020.
You asked the Plan to pay for the shingles vaccine under Medicare Part B. You say that this shot should be covered by the Plan. The Plan denied your request. The Plan says this shot is not covered under Medicare Part B.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine under Medicare Part B. The Plan follows the same rules. Preventative vaccines are not covered under Medicare Part B (other than those listed in the Plan contract). The contract clearly states the shingles vaccine is covered under Medicare Part D only. Therefore, we decided that the Plan does not have to pay for a shingle vaccine provided on November 23, 2020.
Benefits for the shingles vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo Solution 240MG/24ML (CPT code J9299), for the enrollee.
You asked the Plan to pre-approve the medication. You say that the enrollee has lung cancer and has been through multiple lines of treatment with no exposure to immune therapy in the past so you would like to give the enrollee two therapies at the same time in order to get a better response. You state with the goal being to prolong the enrollee's life and help their symptoms because of the lung cancer. You state that with enough information they can go ahead with the treatment because it is needed, the enrollee was on inhibitor before but has been quite a few treatment delays because of another complication the enrollee had from prior chemotherapy. The Plan denied your request. The Plan says medical studies have not proven that the drug(s) is helpful when the enrollee has already tried a similar drug (anti-PD-1 therapy) and did not have a positive response.
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 medication. Our physician reviewer found the rules say that Medicare may cover medically accepted off-label uses for FDA-approved drugs used in an anti-cancer chemotherapeutic regimen. Medicare maintains a list of compendia which define if a use is medically accepted. The off-label use must be supported in one or more of these compendia or in published, peer-reviewed medical literature. An off-label use must be supported in one or more of the compendia and the use must not be listed as unsupported, not indicated, not recommended, or equivalent terms, in any of the compendia. An off-label use may also be determined by the carrier in the state to be reasonable and necessary. In this case, the enrollee has had disease progression when given pembrolizumab, a PD-L1 inhibitor. The National Comprehensive Center Network guidelines do not support the use of Opdivo when there has been progression with prior treatment of pembrolizumab. The elements of the coverage rule are not satisfied. The requested service cannot be recommended.
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 medication have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo Solution 240MG/24ML (CPT code J9299), for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home skilled nursing therapy visits for the enrollee.
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan denied your request. The Plan says the currently approved visits appear to be sufficient to meet the skilled service needs of the enrollee, with further visits not meeting medical necessity criteria.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 visits. Our reviewer says that the requested visits are not medically reasonable or necessary. Our physician reviewer found the enrollee is noted to be non-complaint with treatment, both during and between home nursing visits. The enrollee has family and caregivers that can assist him. As such, ongoing home health nursing services are not shown to be medically necessary or reasonable. 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 visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional home skilled nursing therapy visits for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nail debridement services provided on January 15, 2020, by
an OON provider.
You asked the Plan to pay for podiatry services. You say that you are not responsible for requesting
authorization. The Plan denied your request. The Plan says the denial of payment for this service is correct,
because this provider is out-of-network with the Plan and authorization was not obtained.
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 had network providers
available who could have provided 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 nail debridement services provided on January 15,
2020, by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation miles.
You asked the Plan to pre-approve additional routine transportation miles. You say that you require fifty-four
(54) additional routine transportation miles to attend medical appointments. The Plan denied your request. The
Plan says this service is a covered benefit, but your request exceeds the mileage limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case.
We looked at your request, the records in the case file, and the rules. Based on this information, the 51st trip
and beyond is not a covered benefit. Your 2021 EOC states, "each one-way trip must not exceed fifty (50)
miles of driving distance." Therefore, we decided that the Plan does not have to pre-approve additional routine
transportation miles.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214) for the lower left side.
You asked the Plan to pre-approve the partial denture for the lower left side. You say that you have missing teeth which give you slurred speech and difficulty eating solid foods. You say this partial denture is necessary. The Plan denied your request. The Plan says an upper partial denture has already been approved. You have too many teeth (either natural or prosthetic) that touch to necessitate a partial denture for the lower left side.
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 partial denture for the lower left side 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 partial denture for the lower left side. Our reviewer says that the partial denture for the lower left side is not necessary. Our physician reviewer found that you have good bilateral masticatory function. The criteria for a mandibular removable partial denture (D5214) have not been met. 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 partial denture for the lower left side have not been met. Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5214) for the lower left side.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral/facial photographic image, comprehensive oral evaluation, and complete series of intraoral x-rays provided on December 9, 2020.
You asked the Plan to pay for the 2D oral/facial photographic image, comprehensive oral evaluation, and complete series of intraoral x-rays. You say that prior to your visit you contacted the Plan and were advised you that these services would be covered. The Plan denied your request. The Plan says the 2D oral/facial photographic image is not covered. The Plan also says that your benefits for the comprehensive oral evaluation and complete series of intraoral x-rays have been satisfied and the frequency limitations have been exceeded.
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, 2D oral/facial photographic image is not among those covered under this benefit. The Plan contract says that comprehensive oral evaluation is limited to one procedure every three years, and full mouth or panoramic x-rays are limited to one procedure every five years. The record shows that you received a comprehensive oral evaluation and panoramic x-ray on January 3, 2020, and your comprehensive oral evaluation and full mouth or panoramic x-rays benefits have been exhausted. The record also shows that you were advised the comprehensive oral evaluation and complete series of intraoral x-rays would not be covered. You were given no misinformation during your call with the Plan. Therefore, we decided that the Plan does not have to pay for the 2D oral/facial photographic image, comprehensive oral evaluation, and complete series of intraoral x-rays provided on December 9, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit received on October 27, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says there was no authorization for 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 had network providers available who could have provided 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 an office visit received on October 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Purewick External Female Urinary Collection Device to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the Purewick External Female Urinary Collection Device. You say that this item is medically necessary. The Plan denied your request. The Plan says the requested needs can be met with a standard pouch type female external collection device that is available from an in-network provider.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The provider at issue in this case is not a network provider with the Plan. 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 Purewick External Female Urinary Collection Device. Our reviewer says that the requested item is not medically necessary. Our physician reviewer found there is no specific clinical rationale for the requested device. It has been determined that the request for an out-of-network PureWick External Female Urinary Collection Device is not approved because the requested supplies are available with standard pouch type female external collection devices (A4328) from the Plan's in-network provider. 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 Purewick External Female Urinary Collection Device have not been met. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve the Purewick External Female Urinary Collection Device over the similar device approved by the Plan. Therefore, we decided that the Plan does not have to pre-approve the Purewick External Female Urinary Collection Device to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve physician services. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network specialists available to you that can provide the services you are requesting. The Plan has confirmed with you that you have discharged home with home health services from the skilled nursing facility and you are currently seeing an in-network specialist closer to your home.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve physician services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the placement of intra-socket biological dressing provided on November 17, 2020.
You asked the Plan to pay for the placement of intra-socket biological dressing. You say that you feel you are being incorrectly charged for these services. 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 pay for the placement of intra-socket biological dressing provided on November 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on March 4, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says nonemergent,
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
physician's 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 physician's services provided on March 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided by a participating
provider on December 4, 2020.
You asked the Plan to waive the copayment for an office visit. You say that you were told that you would not
have a copayment for this visit. The Plan denied your request. The Plan says the correct copayment has been
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 $10
copayment for physician/practitioner services/in-network/PCP visits.
You have been asked to pay a $10 copayment for an office visit. The correct copayment has been applied to the
services that were provided. An office visit falls within the physician/practitioner services/in-network/PCP
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 provided by a
participating provider on December 4, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visit and the ultrasound provided on August 24, 2020.
You asked the Plan to waive the copayments for the specialist office visit and the ultrasound. You say that you are appealing the copayments from your visit to the cardiologist. You say you were sent across the hall to have the ultrasound done on the same date of service at the same visit. 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 $50 copayment per visit for specialists and a $50 copayment for each Medicare-covered x-ray or ultrasound. You have been asked to pay a $50 copayment for the specialist office visit and a $50 copayment for the ultrasound. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you were billed by two separate entities for each service.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the specialist office visit and the ultrasound provided on August 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on November 10, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that you were beginning treatment with a new provider and needed a new patient visit. The Plan denied your request. The Plan says the provider is 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 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 office visit provided on November 10, 2020 by an out of network (OON) provider.
Your complaint about the Plan illegally denying the claim 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ketamine infusion services provided on April 6, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the services provided. You say that the enrollee's appeal had been overturned. The Plan denied your request. The Plan says the services were not authorized.
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 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 ketamine infusion services provided on April 6, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) services provided on September 17, 2020.
You asked the Plan to pay for the services provided. You say that an MRI of the left knee was ordered to see if the enrollee has a meniscal tear. The Plan denied your request. The Plan says the billed service cannot be verified.
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 73218 is Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s). We find that CPT code 73218 is not supported in the medical record. The records show that the enrollee received an MRI of the left knee, not an MRI of the upper extremity. 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 magnetic resonance imaging (MRI) services provided on September 17, 2020.