Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a magnetic resonance imagining (MRI) of the pelvis (72197).
You asked the Plan to pre-approve a pelvic MRI. You say that this is indicated. The Plan denied your request. The Plan says that this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 a pelvic MRI. Our reviewer says that the requested MRI is medically necessary. Our physician reviewer found guidelines state that there are insufficient data to recommend routine MRI in every biopsy-nave patient under consideration for prostate biopsy. Its use may be considered in men for whom the clinical indications for biopsy are uncertain (minimal prostate-specific antigen (PSA) increase, abnormal digital rectal examination with normal PSA, or very young or old patients). In this case, the enrollee is biopsy nave. The digital rectal examination demonstrates an enlarged left lobe. The PSA is normal currently although it had previously been elevated. A biopsy indication is uncertain in this enrollee. An MRI for this enrollee in this clinical scenario is medically reasonable and necessary as defined by the coverage rules. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a pelvic MRI have been met. Therefore, we decided that the Plan has to pre-approve a magnetic resonance imagining (MRI) of the pelvis (72197).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Telmisartan, 40mg tablet.
You asked the Plan to pre-approve Telmisartan. You say that you have been well controlled on this medication. You also that your blood pressure is stable. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Telmisartan, 40mg tablet.
Benefits for Telmisartan 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient surgery provided on October 22, 2020.

You asked the Plan to pay for the outpatient surgery. The Plan denied your request. The Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 outpatient surgery provided on October 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical placement of implant body (D6010), prefabricated abutments (D6056), the abutment supported crowns (D6058), and surgical access (D6011) for teeth # 4 and 13.
You asked the Plan to pre-approve the dental services. You say that the services should be covered. The Plan denied your request. The Plan says implants are not covered except to hold complete dentures. The Plan also says that prefabricated abutment is not a covered service. The Plan also says that abutment supported crown is not a covered service either.
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 and implants are listed as covered, the Evidence of Coverage specifically says that implants must be used to hold a complete denture in order to be covered under this benefit. Additionally, prefabricated abutments and abutment supported crowns are not covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the surgical placement of implant body (D6010), prefabricated abutments (D6056), the abutment supported crowns (D6058), and surgical access (D6011) for teeth # 4 and 13.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the porcelain onlay (D2642).
You asked the Plan to pre-approve the dental service. You say that you chipped your back tooth recently. You also say that the purpose of the procedure is restorative and preventative. The Plan denied your request. The Plan says the onlay 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 pre-approve the porcelain onlay (D2642).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a 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 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 services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature and electrical connection.
You asked the Plan to pre-approve power seat elevation feature and electrical connection. You say that this equipment is medically necessary to meet the enrollee's needs. The Plan denied your request. The Plan says the denial of authorization for a power seat elevation feature and electrical connection is correct, because these features are not covered by Medicare. The Plan also says that they have approved the power wheelchair and all other requested components/accessories, so this denial is only for the non-covered power seat elevation feature and electrical connection.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is not primarily medical in nature and is not covered, and an electrical connection for a power seat elevation feature is also not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of power seat elevation feature and electrical connection have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature and electrical connection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve in network coverage of RT300 FES Leg Therapy system (E1399) to be provided by an out of network provider.
You asked the Plan to pre-approve the RT300 FES Leg therapy system. You say that you believe that this request should be about nothing more than the medical necessity of the RT300 and the fact that without it, your present and future health will be at greater risk for decline and early morbidity. The Plan denied your request. The Plan says this device is not covered by neither Medicare or the plan. Medical studies have not proven that the device is helpful for treatment of multiple sclerosis.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the RT300 FES Leg therapy system have not been met. Therefore, we decided that the Plan does not have to pre-approve in network coverage of RT300 FES Leg Therapy system (E1399) to be provided by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vibration foot platform/massager platform and a portable exerciser pedal bike.
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your request. The Plan says these items are not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a vibration foot platform/massager platform and a portable exerciser pedal bike.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physicians services provided on September 3, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that this member recently moved and that is why prior authorization was not obtained. The Plan denied your request. The Plan says prior authorization was not obtained by a participating 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 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 physicians services provided on September 3, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from November 24, 2020, to November 25, 2020.
You asked the Plan to pay for the self-administered drugs. You say that you only took the medications given to you by the hospital staff. You say that you want to know why the medication is considered self-administered. You also say that these should be covered. The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from November 24, 2020, to November 25, 2020.
Benefits for the self-administered drugs 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve access to Special Supplemental Benefits for the Chronically Ill.
You asked the Plan to pre-approve access to Special Supplemental Benefits for the Chronically Ill. You say that you should receive these benefits because you have eyeglasses. The Plan denied your request. The Plan says you do not qualify for these benefits.
Medicare rules say that a supplemental benefit is an item or service not covered by original Medicare. The Plan offers supplemental benefits for chronically ill enrollees. The Plan contract states that if you have been diagnosed by a qualified provider with certain chronic conditions and you meet certain criteria, you may be eligible for additional benefits. We looked at the file and Medicare rules. The record does not show that you have a chronic condition that qualifies for the Plan's supplemental benefits for the chronically ill. Based on this information, we decided that Medicare rules for coverage of access to Special Supplemental Benefits for the Chronically Ill have not been met. Therefore, we decided that the Plan does not have to pre-approve access to Special Supplemental Benefits for the Chronically Ill.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two core buildups, including any pins when required (D2950 x2).
You asked the Plan to pre-approve the core buildups. You say that you would like these services to be approved for coverage. The Plan denied your request. The Plan says this service is not covered.
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 two core buildups, including any pins when required (D2950 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A9999.
You asked the Plan to pre-approve the compression stockings. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of venous stasis ulcers.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A9999 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 A9999.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on August 20, 2020.
You asked the Plan to waive the copayment for the ultrasound. You say that last year the same procedures were used, and you were not charged. You say that the copayment should be canceled. The Plan denied your request. The Plan says the copayment 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 $160 copayment for each Medicare-covered radiological diagnostic service. You have been asked to pay $93.53, which is less than the standard $160 copayment for the ultrasound. The ultrasound falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The ultrasound is considered a diagnostic 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 copayment for the ultrasound provided on August 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a porcelain/ceramic crown (D2740) and core buildup procedure (D2950).
You asked the Plan to pay for the dental services. You say that you need this dental care, and you feel the denial is incorrect because the Plan allows $750 per quarter, not $225. The Plan denied your request. The Plan says you have a $225 benefit allowance for comprehensive dental services per quarter. You used the maximum allowance in January for fillings and another crown. Your benefit has been exhausted for this first quarter.
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 maximum allowance for comprehensive services is $225 per quarter. The Plan provided documentation that your allowance has been exceeded for the first quarter. Therefore, we decided that the Plan does not have to pay for a porcelain/ceramic crown (D2740) and core buildup procedure (D2950) until the next benefit quarter.
Please note: You may wish to contact the Plan to learn when the benefits for the next quarter will be available in order to receive partial payment for these services up to the maximum allowance of $225 per quarter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid services coded 87799, 87798, and 87482 provided on December 9, 2020.
You asked the Plan to pay for the infectious agent detection by nucleic acid 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 Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that the infectious agent detection by nucleic acid services are not supported in the medical record. Specifically, the standard of care for the evaluation of urinary incontinence is urinalysis with urine culture and sensitivity. The polymerase chain reaction (PCR) testing is considered unproven. Based on this information, we decided that Medicare rules for coverage of the infectious agent detection by nucleic acid services have not been met. Therefore, we decided that the Plan does not have to pay for the infectious agent detection by nucleic acid services coded 87799, 87798, and 87482 provided on December 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the requested provider.
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says you must receive your care from a network provider. In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan's network) will not be covered. The requested provider is not contracted with your medical group. The member could switch to one of the Plan's other IPAs and see this ophthalmologist.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by the requested provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a standard wheelchair (K0001).
You asked the Plan to pre-approve a standard wheelchair. You say that you need this item to move around your house The Plan denied your request. The Plan says you already have two items able to meet your medical needs regarding movement.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have power operated vehicle and transport chair. The power operated vehicle and transport chair serves the same purpose as a standard wheelchair. Therefore, we decided that the Plan does not have to pre-approve a standard wheelchair (K0001).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Keytruda (pembrolizumab).
You asked the Plan to pre-approve Keytruda. You say that you believe that treating the enrollee with Keytruda will provide clinical benefit in light of the enrollee's progressive disease. The Plan denied your request. The Plan says the denial of authorization for Keytruda is correct, because the enrollee does not have a diagnosis for which Keytruda may be used.
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 enrollee does not meet the Medicare criteria for the requested use of Keytruda. Our physician reviewer found Keytruda is not FDA-approved for the enrollee's diagnosis. Immunotherapy with checkpoint inhibitors has shown limited activity in most patients with salivary gland tumors, and data are too preliminary to recommend the use of these agents outside of a clinical trial setting. The requested use is not indicated in one of the major drug compendia or in clinical research that appears in a Medicare 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 use of Keytruda (pembrolizumab).