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

We decided that the Plan does not have to waive the copayments for the office visit and imaging services rendered on January 9, 2021 to March 23, 2021.

You asked the Plan to waive the copayments for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayments were 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 $10 copayment for specialty care physician services, a $10 copayment for each x-ray service, and a $100 copayment for diagnostic radiology.

Review of the file shows that you had a specialist office visit on January 9, 2021 and March 23, 2021. You have been asked to pay a $10 copayment for these services for each date of service, for a total of $20. These services fall within the specialty care physician services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.

The file shows that you had an external electrocardiogram (EKG) on February 18, 2021. You have been asked to pay a $10 copayment for these services. These services fall within the x-ray benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.

The file shows that you had a diagnostic mammogram on March 16, 2021. Per the contract with the Plan, there is a $100 copayment for diagnostic radiology. However, the Medicare allowed amount for these services was $52.57. Given that the allowed amount was less than the $100 copayment, you have been asked to pay $52.57 for these services.

The total amount you have been asked to pay for these services is $82.57. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the office visit and imaging services rendered on January 9, 2021 to March 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hair prosthesis.

You asked the Plan to pre-approve a hair prosthesis. You say that a hair prosthesis would constitute durable
medical equipment. The Plan denied your request. The Plan says wigs are for comfort and to improve
appearance, neither Medicare nor the Plan cover wigs.

Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are
ordered by a physician. The Plan follows these same rules.

In this case, although a hair prosthesis may be appropriate, it does not meet the definition of the above benefit
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would
provide coverage for a hair prosthesis. Therefore, we decided that the Plan does not have to pre-approve a hair
prosthesis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the weather cover and cup holder (CPT code K0108 X2).
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your request. The Plan says Medicare guidelines say that durable medical equipment is primarily and customarily used to serve a medical purpose.
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 the weather cover and cup holder (CPT code K0108 X2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #7.

You asked the Plan to pre-approve the crown. You say that part of the crown that you had on this tooth fell out.
The Plan denied your request. The Plan says the crown for tooth # 7 is not medically necessary because
maintenance of the tooth is not appropriate in view of your overall dental status (missing teeth and/or decay).

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the crown
when the services are medically necessary and reasonable.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the crown. Our reviewer says that the crown for tooth #7 is not currently medically necessary. Our physician reviewer found it is unknown as to the condition of the teeth posterior to #6 or #8, or if they are present in the dental arch. While it is clear that tooth #7 has lost an existing crown and may need replacement, the condition of the adjacent teeth should be clarified and as well as the presence and condition of the other teeth in the maxillary arch. Our reviewer found that if the adjacent teeth are compromised it may affect the overall treatment plan. Our physician reviewer also found that it cannot be ascertained definitively that the radiolucencies around tooth #'s 6 and 8 are just the result of short crown margins and not decay, and the condition of the remainder of the arch is not determinable due to lack of x-rays. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) for tooth #7.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87486, 87496, 87498, 87500, 87502, 87532, 87541, 87581, 87634, 87640, and 87641) provided August 4, 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 87486, 87496, 87498, 87500, 87502, 87532, 87541, 87581, 87634, 87640, and 87641 are not supported in the medical record. Specifically, the place of service on the claim (11, office setting) does not match the place of service detailed in the records (31, Skilled Nursing Facility). 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 (87486, 87496, 87498, 87500, 87502, 87532, 87541, 87581, 87634, 87640, and 87641) provided August 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda injection (J7921).

You asked the Plan to pre-approve Keytruda injection, pembrolizumab, 1 mg (J9271) and ramucirumab and paclitaxel regimen. You say that you want to treat the enrollee with this drug regimen. The Plan denied your request. The Plan says the drug regimen is not supported for recurrent progressive non-small cell lung cancer.

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 injection, pembrolizumab, 1 mg (J9271) and ramucirumab and paclitaxel regimen. Our reviewer says that the requested use of Keytruda injection, pembrolizumab, 1 mg (J9271) is not FDA-approved for the enrollee's diagnosis in combination with paclitaxel and ramucirumab. Our physician reviewer found the use is not supported by the major drug compendia or by clinical research that appears in a CMS-approved medical journals.

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 injection, pembrolizumab, 1 mg (J9271) and ramucirumab and paclitaxel regimen have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda injection (J7921).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that these orthotics are related to an ankle-foot orthosis. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. An ankle-foot orthosis is not considered to be a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services with dental code D2950 provided on October 13, 2020.
You asked the Plan to pay for dental code D2950. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says dental code D2950 is not covered under the Plan's supplemental dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, dental code D2950 is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services with dental code D2950 provided on October 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on March 18, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit provided on March 18, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a mammogram (77066) provided January
28, 2021.

You asked the Plan to waive the copayment for the mammogram. You say that the copayment should be
waived. The Plan denied your request. The Plan says the correct copayment 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
copayment for x-rays.

You have been asked to pay a $30 copayment for the mammogram. The mammogram falls within the x-rays
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 a mammogram (77066) provided
January 28, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital surgical services
provided February 12, 2021.

You asked the Plan to waive the copayment for the outpatient services. You say that this was a wellness
procedure and believe there should be no deductible or copay applied The Plan denied your request. The Plan
says the claim processed with the correct copayment applied per the Evidence of Coverage.

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 $395
copayment for each Medicare covered outpatient hospital visit after you meet the $395 deductible.

You have been asked to pay $395 copayment for the outpatient services. The outpatient services fall within the
Outpatient hospital 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. Therefore, we decided that the Plan does not have to waive the copayment for the
outpatient hospital surgical services provided February 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office services provided on October 13, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the office services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 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 office services provided on October 13, 2020 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 28, 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 the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in a skilled nursing facility setting and should have been billed with POS code 31. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 28, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from January 11,
2020, to January 20, 2020.

You asked the Plan to pay for SNF care. You say that you are seeking reimbursement for these charges. The
Plan denied your request. The Plan says the denial of payment for these services is correct, because this claim
was not submitted within the timely filing limit.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.

The record shows that a claim for SNF care was not filed until February 3, 2021. This means that more than
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the
Plan does not have to pay for skilled nursing facility (SNF) care provided from January 11, 2020, to January
20, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided on December
8, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered
benefit.
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 psychiatric diagnostic evaluation provided on
December 8, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network orthopedic surgeon.

You asked the Plan to pre-approve these services. You say that numerous people told you this provider was in-network. 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. 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 orthopedic surgeon.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Breyanzi.
You asked the Plan to pre-approve Breyanzi. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says that the requested drug is not medically reasonable and necessary.
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 Breyanzi. Our reviewer says that this service is medically necessary for the enrollee's condition. Our physician reviewer found the enrollee has a history of diffuse large B-cell lymphoma and mantle cell lymphoma. In this case, the requested drug is not FDA-approved for the enrollee's condition. However, per the National Comprehensive Cancer Network's compendia, this drug is medically necessary as the enrollee has received greater than or equal to 2 lines of therapy with one being an anthracycline for indolent or transformed disease. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Breyanzi have been met. Therefore, we decided that the Plan has to pre-approve Breyanzi.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.

You asked the Plan to provide coverage additional routine transportation trips. The Plan denied your request. The Plan says your benefit only allows for 60 one-way trips per year.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

We looked at your request, the records in the case file, and the rules. The Plan only allows for 60 one-way trips per year. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two crowns (D2740 x2).

You asked the Plan to pre-approve the crowns. The Plan denied your request. The Plan says this service is not covered under your benefit 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 pre-approve two crowns (D2740 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services provided on April 29, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for podiatry services. You say that these should be considered separate and distinct services. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for podiatry services provided on April 29, 2021 by an out-of-network (OON) provider.