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

We decided that the Plan does not have to pay for chiropractic services (99201) provided December 11, 2020 to December 14, 2020.

You asked the Plan to pay for the chiropractic services. You say that the services were medically necessary. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic services (99201) provided December 11, 2020 to December 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87500, 87563, 87801) provided August 6, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the documentation does not support the services billed.

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 CPT codes 87500, 87563, & 87801 are not supported in the medical record. Specifically, the place
of service on the claim (81, laboratory) does not match the place of service described by the records (11, office
setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not
been met. Therefore, we decided that the Plan does not have to pay for lab services (87500, 87563, 87801)
provided August 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on November 17, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. You say that your lab performed all the tests that were ordered by the referring physician. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that the referring 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 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 lab work provided on November 17, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0481) provided July 20, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the documentation does not support the services billed.
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 CPT code G0481 is not supported in the medical record. Specifically, the place of service listed on
the claim (81, laboratory) does not match the place of service described in the record (11, office setting). Based
on this information, we decided that Medicare rules for coverage of the lab services have not been met.
Therefore, we decided that the Plan does not have to pay for lab services (G0481) provided July 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve disposable sensors.
You asked the Plan to pre-approve disposable sensors. You say that the items 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. Medicare rules say that that plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers as long as the enrollee retains access to all medically necessary items (including non-preferred brands). We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of disposable sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve disposable sensors.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
You asked the Plan to pre-approve a power seat elevation system. You say that the item is necessary. The Plan denied your request. The Plan says the item is not primarily medical in nature. Therefore, coverage criteria are not met.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power seat elevation system have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0482) provided June 23, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the documentation does not support the services billed.
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 CPT code G0482 is not supported in the medical record. Specifically, the place of service on the
claim (81, laboratory) does not match the place of service described in the records (11, office setting). Based on
this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore,
we decided that the Plan does not have to pay for lab services (G0482) provided June 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent.
You asked the Plan to pre-approve Dupixent. You say that this medication works for the enrollee, and other oral and topical regimens have failed. The Plan denied your request. The Plan says this medication does not fall under 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 Dupixent.
Benefits for Dupixent 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for home health services (G0299, G0151,
Q5001) provided August 4, 2020, to August 28, 2020.
You asked the Plan to waive the coinsurance for the home health services. You say that the coinsurance should
be waived. The Plan denied your request. The Plan says the correct cost-sharing was 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 30%
coinsurance for home health services.
You have been asked to pay a 30% coinsurance for the home health services. 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 home health services (G0299, G0151, Q5001) provided August 4, 2020, to August
28, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (G0299) provided December 7, 2020,
to December 10, 2020.
You asked the Plan to pay for the home health services. You say that the services were medically necessary.
The Plan denied your request. The Plan says a corrected claim is needed.
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 CPT code G0299 is not supported in the medical record. Specifically, the claim did not include a
valid Type of Bill. Based on this information, we decided that Medicare rules for coverage of the home health
services have not been met. Therefore, we decided that the Plan does not have to pay for home health services
(G0299) provided December 7, 2020, to December 10, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services described by current procedural terminology (CPT) code 81003 provided on September 21, 2020.

You asked the Plan to pay for CPT code 81003. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We looked at the file and Medicare rules. In this case, CPT code 81003 is not listed as a test for provider-performed microscopy procedures and was not billed with a QW modifier per the CLIA list of Waived Tests. Furthermore, the provider's CLIA expired on August 31, 2020, before the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the laboratory services described by current procedural terminology (CPT) code 81003 provided on September 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the injections received on December 10, 2020.
You asked the Plan to waive the coinsurance for the injections. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says the enrollee received injections on the date of service at issue in this appeal. The Plan says that the correct coinsurance has applied per the enrollee's contract with the Plan.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a 20% coinsurance for Medicare Part B prescription drugs. We looked at the file, the Plan's contract and Medicare rules. The file shows that the enrollee received injections on December 10, 2020. The enrollee has been asked to pay a 20% coinsurance for the injections, totaling $714.33. The injections fall within the Medicare Part B prescription drugs benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the injections received on December 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmology services (92133, 92202, 99214) provided
on January 19, 2021, by an OON provider.
You asked the Plan to pay for the ophthalmic care. You say that you did not know that you needed a referral to
see this provider, or that you did not have approval. The Plan denied your request. The Plan says out-of-network
services are not covered. No referral was provided, nor was prior authorization granted for these
services. The Plan also states that you requested services with this provider in 2020, but this request was denied
because the Plan has providers who are available to provide these services in-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 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 the ophthalmology services (92133, 92202,
99214) provided on January 19, 2021, by an OON provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient mental health services (90837) provided January 14, 2021 to January 21, 2021.
You asked the Plan to waive the copayment for the outpatient mental health services. You say that the copayments should be waived. The Plan denied your request. The Plan says the correct copayments were 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 $25 copayment for Outpatient mental health care. You have been asked to pay a $25 copayment for each outpatient mental health visit. The outpatient mental health services fall within the Outpatient mental health care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient mental health services (90837) provided January 14, 2021 to January 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment the MRI provided on September 16, 2020.
You asked the Plan to waive the copayment the MRI. You say that you have a $100 copayment per visit. You
say you had two pictures taken at one 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 $100
copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in an in-network 
physician's office or at a freestanding facility (such as a radiology center or medical clinic).
You have been asked to pay a $100 copayment for the MRI. The MRI falls within the "Outpatient Diagnostic
Tests and Therapeutic Services and Supplies" benefit category. The record shows you received two separate
MRIs at one visit. 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 the MRI provided on September 16,
2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Carboplatin (J9045), Pemetrexed (J9305), and Pembrolizumab (J9271).
You asked the Plan to pre-approve the Carboplatin, Pemetrexed, and Pembrolizumab. You say that you would like the enrollee to be treated with this chemotherapy regimen. The Plan denied your request. The Plan says these drugs are not supported in the National Comprehensive Cancer Network (NCCN) guidelines. The Plan also says that the NCCN guidelines support other treatment options.
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 Carboplatin, Pemetrexed, and Pembrolizumab. Our reviewer says that these drugs are not medically reasonable and necessary for the enrollee. Our physician reviewer found that there are plans to treat the enrollee with a drug treatment (Carboplatin/Pemetrexed/Pembrolizumab). This treatment is recommended only for cancers that are of a certain stage. The stage of the cancer is assigned based on the size of the cancer and how much it has spread. This treatment is not recommended by the NCCN for the enrollee's cancer stage. Our reviewer also found that the review has determined that the requested use of Carboplatin (J9045), Pemetrexed (J9305), and Pembrolizumab (J9271) is not FDA-approved for the enrollee's diagnosis. Its use is not supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services (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 the Carboplatin, Pemetrexed, and Pembrolizumab have not been met. Therefore, we decided that the Plan does not have to pre-approve Carboplatin (J9045), Pemetrexed (J9305), and Pembrolizumab (J9271).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the endodontic therapy, molar tooth
(excluding final restoration) (D3330) provided December 22, 2020.
You asked the Plan to provide additional payment for the root canal. You say that you were not aware that the
dentist was not in the Plan's network and you cannot afford the high cost of the bill. The Plan denied your
request. The Plan says the claim has processed correctly, and you are responsible for a greater share of the bill
because you used an out-of-network provider.
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 root canals
when the services are medically necessary and reasonable.
We looked at the file and Medicare rules. The Plan paid 50% of the contracted allowed amount for the service.
This leaves you with a responsibility for 50% of the allowed amount plus the difference between the allowed
amount and the total amount billed by the non-contracted provided. This means that you have been asked to
pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have
to provide additional payment for the endodontic therapy, molar tooth (excluding final restoration) (D3330)
provided December 22, 2020.
Your complaint about not being aware that the dentist was not in the Plan's dental provider's network 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that this is necessary for the enrollee to regain he ability
to do day to day activities. The Plan denied your request. The Plan says the enrollee's needs can be met in a less
intensive setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee does not require treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical
record supports a need for physical or occupational therapy, there is no documented need for intensive
rehabilitation services. Medically necessary care can be provided in a different level 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 IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the CPAP supplies provided on March 13, 2020.

You asked the Plan to waive the coinsurance for the CPAP supplies. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received durable medical equipment on the date of service at issue in this appeal. The Plan says that the correct coinsurance has applied per your contract with the Plan.

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 Durable medical equipment. 

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received CPAP supplies on March 13, 2020. You have been asked to pay a 20% coinsurance for the CPAP supplies, totaling $67.65. The CPAP supplies fall within the Durable medical equipment 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 CPAP supplies provided on March 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D0120, D0220, D0230, D1110) received January 5, 2021.
You asked the Plan to pay for the dental services. You say that the Plan should pay for the dental services. The Plan denied your request. The Plan says your supplemental benefit does not include routine dental care.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. You do not have the Plan's supplemental benefit which covers routine dental services. Therefore, we decided that the Plan does not have to pay for the dental services (D0120, D0220, D0230, D1110) received January 5, 2021.