Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction provided on July 21, 2020. 
 
You asked the Plan to pay for the surgical extraction. You say that you were told that the insurance company 
would pay for this. You also say that you were not advised that this provider has opted out of Medicare. The 
Plan denied your request. The Plan says payment is unable to be made because this provider has opted out of 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
surgical extraction provided on July 21, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on June 22, 
2020. 
 
You asked the Plan to pay for the physician service. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent nursing facility care provided on June 22, 
2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network provider. 
 
You asked the Plan to pre-approve these services. You say that the Plan provider is no longer accepting new 
patients. The Plan denied your request. The Plan says the services are available from network providers. 
 
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. The Plan confirmed that the network 
provider is able to see the enrollee as early as January 12, 2021. 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 a 
referral to an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retrobulbar injection provided on July 29, 2020. 
 
You asked the Plan to pay for the services provided. You say that Medicare pays these without having to 
appeal claims. The Plan denied your request. The Plan says the claim was processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. The services at issue are an integral part of the approved primary anesthesia 
code. Accordingly, it is inappropriate to separately report these services. Based on this information, we decided 
that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for the retrobulbar injection provided on July 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
August 31, 2020. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you have been charged 
the correct cost sharing amount. 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 $20 
copayment for services obtained from an in-network specialist. Or, under certain circumstances, by a nurse 
practitioner or physician's assistant or other non-physician health care professionals.  
 
You have been asked to pay a $20 copayment for the specialist office visit. The specialist office visit falls 
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 specialist office visit provided on August 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that 
were issued on September 8, 2020. 
 
You asked the Plan to pay for the compression stockings. You say that the records provided should support the 
necessity of the service in dispute. The Plan denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 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 pay for the compression 
stockings identified with code A6530 that were issued on September 8, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0425, A0427) provided on June 14, 
2020. 
 
You asked the Plan to pay for ambulance services. You say that this was billed correctly. The Plan denied your 
request. The Plan says this was billed with incorrect diagnosis codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that some ICD-10-CM codes indicate laterality. If the side is not identified in the medical record, 
assign the code for the unspecified side. 
 
We find that the billing of this claim is not supported in the medical record. Specifically, this claim was billed 
with both diagnosis M25.531, pain in right wrist, and diagnosis M25.539, pain in unspecified wrist. The 
records indicate that the enrollees pain was in the right wrist, therefore an unspecified code is not appropriate. 
Based on this information, we decided that Medicare rules for coverage of ambulance services have not been 
met. Therefore, we decided that the Plan does not have to pay for ambulance services (A0425, A0427) 
provided on June 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care (99308) provided on July 28, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for OON nursing facility care. You say that this service was provided in good faith. 
The Plan denied your request. The Plan says this service was 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the nursing facility care (99308) provided on July 
28, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the predictive screening testing July 9, 2020. 
 
You asked the Plan to pay for the screening test. You say that please be advised the referring physician ordered 
specialized testing and forwarded the tests directly to you. You do not have direct patient contact. The Plan 
denied your request. The Plan says predictive screening testing is not a Medicare benefit. Screening services 
with no relation to a medical diagnosis of a disease for the health of the patient are not benefit. 
 
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, the screening test, 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 predictive screening testing July 9, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on July 22, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that it is the facility's responsibility to obtain 
prior authorization. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for skilled nursing services provided on July 22, 2020 
by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The 
Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed 
above 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 SNF care. Our reviewer says that daily skilled services are not 
necessary. Our physician reviewer found you do 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. Your functional level does not require skilled therapy services with the specialized skill, 
knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable 
treatment in a SNF. You do not require skilled nursing or skilled therapy services (or a combination of these services) on 
a "daily basis" in a SNF. As a practical matter, you do not require the necessary services on an inpatient basis, in a skilled 
nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve 
skilled nursing facility (SNF) care.
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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. 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 Keytruda. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found Pembrolizumab is not FDA approved for 
the 1st line treatment of metastatic pancreatic cancer. It is not supported for off-label use by major drug 
compendia or the medical literature in enrollees that lack MSI-high or d-MMR. Gemcitabine, fluorouracil, or a 
taxane as monotherapy is recommended for 1st line treatment in enrollees with performance status of 2 or with 
a comorbidity profile that precludes intensive therapy. The service is not reasonable or medically necessary. 
 
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 waive the copayment for integrated biopsychosocial assessment 
(90791) provided June 24, 2020 
 
You asked the Plan to waive the copayment for the assessment. You say that you have never talked to the 
doctors other than having a virtual session with this provider. The Plan denied your request. The Plan says this 
claim was processed and the correct copayment 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 $40 
copayment for specialty care physician.  
 
You have been asked to pay $40 copayment for the assessment. The assessment falls 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 integrated biopsychosocial assessment (90791) provided June 24, 2020
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for portable x-ray services (Q0092, R0070) provided on May 20, 
2020. 
 
You asked the Plan to pay for portable x-ray services. You say that these are payable codes. The Plan denied 
your request. The Plan says these services were not billed correctly. 
 
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. 
 
We find that CPT codes Q0092 and R0070 are not supported in the medical record. Specifically, no medical 
records have been submitted. Without this documentation, these codes cannot be verified. Based on this 
information, we decided that Medicare rules for coverage of portable x-ray services have not been met. 
Therefore, we decided that the Plan does not have to pay for portable x-ray services (Q0092, R0070) provided 
on May 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fulphila. 
 
You asked the Plan to pre-approve Fulphila. You say that the medication is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. 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 Fulphila. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the requested use would not meet that 
recommendation as the enrollee is receiving daily Lenalidomide which is a drug that can lower blood counts. 
Therefore the requested use of the long acting myeloid growth factor is not medically reasonable and necessary 
and is not safe and effective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Fulphila have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Fulphila.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-cement or re-bond crown (D2920) provided on August 
24, 2020. 
 
You asked the Plan to pay for the dental service. You say that you were advised that the provider had used an 
incorrect code on the claim that was submitted. You say that you wasted a lot of time on phone calls with the 
provider and your insurance. You say that your dental brochure says that coverage includes fillings, root canals, 
simple extractions, crown repairs and crowns. You say that based on this, the service you received should be 
covered. The Plan denied your request. The Plan says re-cement or re-bond of a 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. Therefore, we decided that the Plan does not have to pay for the re-
cement or re-bond crown (D2920) provided on August 24, 2020.  
 
Your complaint about spending 4 hours on the phone 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the ostomy supplies provided on July 2, 2020. 
 
You asked the Plan to waive the coinsurance for the ostomy supplies. You say that you didn't receive an explanation of 
benefits in the mail. You say that you cannot afford the cost. The Plan denied your request. The Plan says 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 clearly says that you must pay 20% coinsurance 
for Medicare-covered ostomy supplies. 
 
You have been asked to pay a total of $40.92 for the ostomy supplies.  
 
Supply Allowed Amount Coinsurance Member Liability 
Ostomy Skin Barrier $114.40 20% $22.88 
Ostomy Pouch $83.20 20% $16.64 
Skin Barrier $7 20% $1.40 
TOTAL:   $40.92 
 
The ostomy supplies fall within the "Prosthetic devices and related supplies" 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 ostomy supplies provided on July 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing services rendered on March 2, 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 procedure code 95999 is not supported. 
 
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 95999 is unlisted neurological or neuromuscular 
diagnostic procedure. 
 
We find that CPT code 95999 is not supported in the medical record. Specifically, the records show that Train 
of Four testing was performed and there is a more appropriate code for these services. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the testing services rendered on March 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital services provided on July 23, 2020. 
 
You asked the Plan to pay for the hospital services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the hospital services provided on July 23, 2020.