Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve6 additional occupational therapy visits.You asked the Plan to pre-approve6 additional occupational therapy visits. You say that you need continued therapy.The Plan denied your request. The Plan says additional visits are not 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 6 additional occupational therapy visits. 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 based on the available records, you appear to have plateaued with therapy. Further formal therapy at this point does not appear to be likely to achieve any significant improvement in your symptoms or functional status. Further utilization of the home exercise program appears appropriate at this point.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 6 additional occupational therapy visits have not been met.Therefore, we decided that the Plan does not have to pre-approve6 additional occupational therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom abutment (D6057) and the implant supported crown (D6065) provided on July 8, 2020.
You asked the Plan to pay for the dental services. You say that you had an implant done in November 2019 and it finished in July of this year. You say that you had to have the tooth put on in July but it was denied. You say that you were advised that pre-authorization was required but you have never had to do that before. The Plan denied your request. The Plan says the custom abutment is not listed as a covered service. The Plan also says that the implant supported crown is not listed as a covered 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. 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. Although the implant supported crown is listed in the ORM as a covered service, it was provided as a result of a non-covered service. Therefore, we decided that the Plan does not have to pay for the custom abutment (D6057) and the implant supported crown (D6065) provided on July 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. You say that this is medically necessary. The Plan denied your
request. The Plan says the requested use is not 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 Keytruda. Our reviewer says that the
criteria for coverage of Keytruda have not been met. Our physician reviewer found the requested use of
Keytruda is not FDA-approved for the enrollee's diagnosis. Some cancers with deficient mismatch repair
(dMMR; the biologic footprint of which is high levels of microsatellite instability [MSI-H]) are particularly
sensitive to immune-based therapies. These tumors, which have high levels of tumor mutational burden (TMB),
are thought to be more immunogenic and responsive to immune checkpoint inhibitor immunotherapy. The
enrollee does not have either of these. The use is also not supported by one of the major drug compendia or by
clinical research that appears in a CMS-approved medical journal.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have
to pre-approve Keytruda.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power wheelchair to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe power wheelchair from an OON provider. You say that the OON provider is threatening to pick up the power wheelchair that was previously approved by Medicare. You say that you have Lou Gehrig's Disease and that the requested device is medically necessary.The Plan denied your request. The Plan says medically necessary durable medical equipment is available in-network.Medicare rules say that planscan 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-approvea power wheelchair to be provided by an out of network (OON) provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the chemotherapy services rendered on January 17, 2020.
You asked the Plan to waive the coinsurance for these services. You say that there should be no coinsurance. 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 Part B covered chemotherapy drugs.
Review of the file shows that you received chemotherapy services on January 17, 2020. You have been asked to pay a 20% coinsurance for these services. These services fall within the Part B covered chemotherapy drugs 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 chemotherapy services rendered on January 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe Osteoporosis Injections (J0897) administered on February 24, 2020, through February 29, 2020.You asked the Plan to waive the copayment forthe Osteoporosis Injections. You saidthat you had received the denosumab injections three times, but this was the first time you have received a bill.The Plan denied your request. The Plan says $805.84 is your cost-share,a20% coinsurance is required for the Medicare Part B drugs.The rules say a plan must disclose to its enrollees in clear, a term allcost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay $805.84 coinsurance forOsteoporosis injections($4029.20x 20%=$805.84).The Osteoporosisinjections fall within the Medicare Part Bdrugsbenefit 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 forthe Osteoporosis Injections (J0897) administered on February 24, 2020, through February 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe thoracoscopy services coded 32674 and the tube or needle catheter jejunostomy for enteral alimentation, intraoperative, any method services coded 44015 provided on June 30, 2020.You asked the Plan to pay forthe thoracoscopy services and the tubeor needle catheter jejunostomy for enteral alimentation, intraoperative, any method services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not payable.The Planmust 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 32674 is thoracoscopy, surgical; with mediastinal and regional lymphadenectomy (List separately in addition to code for primary procedure). The CPT Code Manual definition of code 44015 is tube or needle catheter jejunostomy for enteral alimentation, intraoperative, any method (List separately in addition to primary procedure).We find that CPT codes 32674 and 44015 are not supported in the medical record. Specifically, these codes are add-on codes. These codes were billed without a primary service or procedure. Based on this information, we decided that Medicare rules for coverage of the thoracoscopy services and the tube or needle catheter jejunostomy for enteral alimentation, intraoperative, any method services have not been met.Therefore, we decided that the Plan does not have to pay forthe thoracoscopy services coded 32674 and the tube or needle catheter jejunostomy for enteral alimentation, intraoperative, any method services coded 44015 provided on June 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe complete maxillary denture (D5110) and complete mandibular denture (D5120) provided on July 22, 2020.You asked the Plan to pay forcomplete maxillary denture and complete mandibular denture. You say that you were advised that there was no coverage for temporary dentures, and 50% coverage for permanent dentures.The Plan denied your request. The Plan says these procedures are not covered underyour dental 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, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe complete maxillary denture (D5110) and complete mandibular denture (D5120) provided on July 22, 2020
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay forMammaPrinttesting (81521) provided on September 9, 2020.You asked the Plan to pay forMammaPrint testing. You say that this is a covered service.The Plan denied your request. The Plan says that this testing was not medically necessary.The Plan must follow Medicare rules. Medicare rules say that MammaPrint testing is covered when medically necessary according to the guidelines listed above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for MammaPrint testing. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found gene expression profiling is medically reasonable and necessary in patients with ER+, HER2-T1b to T3, node negative disease such as this enrollee has. MammaPrint has been prospectively, clinically validated for use in early stage breast cancer patients with a specific tumor size; 5.0 cm, and 0-3 positive lymph nodes.
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MammaPrint testing have been met.Therefore, we decided that the Plan has to pay forMammaPrint testing (81521) provided on September 9, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on September 25, 2020.You asked the Plan to pay forthe services. 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 thePlan 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 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 forthe medical services provided to the enrollee by an out-of-network provider on September 25, 2020
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forout of network physician services provided from September 19, 2019 to February 20, 2020.You asked the Plan to pay forthis service. You say that these services should be covered by the Plan.The Plan denied your request. The Plan says you did not have prior authorization for out of network care.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 forcare 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 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 forout of networkphysician services provided from September 19, 2019 to February 20, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pre-approvethe Oncotype DX Breast Cancer Assay.You asked the Plan to pre-approvethe Oncotype DX Breast Cancer Assay. You say that you would like reconsideration because this testing is medically necessary.The Plan denied your request. The Plan says that the documentation does not show that the lymph nodes have been tested for cancer.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 the Oncotype DX Breast Cancer Assay. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found this member is receiving neoadjuvant endocrine therapy and oncotype requested to rule out the need for chemotherapy. She is clinically node negative by ultrasound. The use of OncotypeDx in the neoadjvuant setting for clinically node negative ER+ HER2 negative breast cancer patients is a standard of care.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 Oncotype DX Breast Cancer Assay have been met.Therefore, we decided that the Plan has to pre-approvethe Oncotype DX Breast Cancer Assay.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 toopen the case again, we will send you a letter
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued inpatient behavioral health services.You asked the Plan to pre-approvecontinued services. The Plan denied your request. The Plan says there is no evidence of danger to self or others.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. Continued inpatient services from January 27, 2021, forward, were requested. 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 continued services. Our physician reviewer found that active treatment was not taking place. It did not appear that the services were reasonably expected or medically necessary to improve the enrollee'scondition,or for the purpose of diagnosis. The enrollee can betreated in a lesser,restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions,and was not showing any behaviors or aggression. He was being cooperative and compliant while not showing any acute threats to safety as heawaited placement.Based upon review the records provided, he does not meet the criteria for treatment in an acute inpatient mental health treatment beyond January 27, 2021.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued inpatient behavioral health services.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEnsure Plus.

You asked the Plan to pre-approveEnsure. You say that the enrollee is stable on Ensure.The Plan denied your request. The Plan says Ensure is not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation.

The items you asked the Plan to pre-approve are nutritional supplements.Therefore, we decided that the Plan does not have to pre-approveEnsure Plus
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forspecialist telemedicine visits provided on May 19, 2020, and June 16, 2020.You asked the Plan to waive the copayment forspecialist telemedicine visits. You say that you don't believe these visits took place.The Plan denied your request. The Plan says these services processed 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 each visit with a specialist. You have been asked to pay a $40 copayment for each of two specialist telemedicine visits for a total of $80. The medical records confirm these services took place. 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 forspecialist telemedicine visits provided on May 19, 2020, and June 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe radiation therapy rendered form August 10, 2020 to September 2, 2020.You asked the Plan to waive the coinsurance forthese 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 discloseto 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% coinsurance for radiation therapy at an out-of-network outpatient hospital. Review of the file shows that you received radiation therapy from an out-of-network provider from August 10, 2020 to September 2, 2020. You have been asked to pay a 50% coinsurance for these services. These services fall within the radiation therapy at an out-of-network outpatient hospital 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 forthe radiation therapy rendered form August 10, 2020 to September 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe chiropractic services rendered on August 10, 2020.You asked the Plan to waive the copayment forthese services. You say that the provider did not notify you of the charges.The Plan denied your request. The Plan says the copayment 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 copayment for chiropractic services. Review of the file shows that you received chiropractic manipulation services on August 10, 2020. You have been asked to pay a $20 copayment for these services. These services fall within the chiropractic 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.The Plan must follow Medicare rules. The rules say that the onlychiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. The file shows that the provider submitted a claim for an office visit. These services are not covered by Medicare when billed by a chiropractor.Therefore, we decided that the Plan does not have to waive the copayment forthe chiropractic services rendered on August 10, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not haveto pre-approvea set of dentures (D5110, D5120).You asked the Plan to pre-approvea set of dentures. You say that your partial dentures do not fit right and you are in constant pain.The Plan denied your request. The Plan says your benefit is exhausted for the 2021 plan year.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 a set of dentures once every 5 years.We looked at the case file and Medicare rules. The record indicates that you previously received dentures on November 27, 2019. This date of service is less than 5 years ago. Based on this information, we decided that the Plan's rules for coverage of a set of dentures have not been met.Therefore, we decided that the Plan does not have to pre-approvea set of dentures (D5110, D5120).