Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on January 15, 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 approved for 
payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that 
the member's primary care physician did not refer these services. 
 
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 lab work provided on January 15, 2020 by an out 
of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and related services provided on January 21, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for these OON services. 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 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 office visit and related services provided on 
January 21, 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 provided to the enrollee from January 7, 2019 to 
May 28, 2019. 
 
You asked the Plan to pay for the services. You say that  The Plan denied your request. The Plan says the 
services were not pre-certified. 
 
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 lab services provided to the enrollee from January 
7, 2019 to May 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the facility fee provided on March 5, 2020.
You asked the Plan to waive the copayment for the facility fee. You say that you should not have to pay a second charge. You say you already paid your $50 copayment for the office visit. 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 $325 copayment for each Medicare-covered in-network outpatient hospital visit or hospital outpatient surgical facility visit. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $325 copayment for the facility fee.
You have been asked to pay a $133.58 copayment for the facility fee. The facility fee falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 facility fee provided on March 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Feraheme for the enrollee.
You asked the Plan to pre-approve Feraheme. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the medical information they received shows that the enrollee has not met the criteria for continuation of iron infusion based on your recent iron studies.
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 Feraheme. Our reviewer says that Feraheme is not medically reasonable and necessary for the enrollee. Feraheme is not FDA-approved for the enrollee's diagnosis. The enrollee does not have iron deficiency or renal insufficiency. Labs are not consistent with low iron, saturation >20% ferritin 833. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The use is not listed as not indicated, not supported or not recommended in any of the compendia. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for Feraheme. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have to pre-approve Feraheme for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy. 
 
You asked the Plan to pre-approve proton beam radiation therapy. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 proton beam radiation therapy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has T2No gleason 7 and Prostate-specific antigen 12 prostate 
cancer. The NCCN radiation therapy compendia, choices are brachytherapy and EBRT for intermediate risk 
group and definitive therapy. Proton beam therapy is not listed. Ongoing studies still deem proton beam 
therapy as experimental/investigational. Therefore, the enrollee does not meet criteria for the requested 
services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve proton beam radiation therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laparoscopy and related services provided on January 21, 
2020. 
 
You asked the Plan to pay for the laparoscopy and related 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 laparoscopy and related services are not supported in the medical record. Specifically, the code for 
the laparoscopy services, CPT 58575 is an inpatient only code. Therefore, this is not payable unless submitted 
under inpatient services. Based on this information, we decided that Medicare rules for coverage of the 
laparoscopy and related services have not been met. Therefore, we decided that the Plan does not have to pay 
for the laparoscopy and related services provided on January 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox injections for the enrollee.
You asked the Plan to pre-approve Botox injections. You say that that the enrollee needs this to treat frequent headaches. The Plan denied your request. The Plan says that this is not covered for the enrollee's diagnosis.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Botox injections. Our reviewer says that Botox injections are not medically reasonable and necessary for the enrollee in this case. The effectiveness of Botox injection to treat cervicalgia with nonspecific headache has not been established. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for Botox injections. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox injections for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retreatment of previous root canal therapy (D3348) provided on February 3, 2020.
You asked the Plan to pay for the retreatment of previous root canal therapy. You say that this should be covered. The Plan denied your request. The Plan says this is excluded from coverage.
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 retreatment of previous root canal therapy (D3348) provided on February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pulmonary services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON services. You say that the enrollee has trouble driving long distances. The Plan denied your request. The Plan says there are in-network options within 30 miles that are able to service the enrollee's needs.
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 OON services. Therefore, we decided that the Plan does not have to pre-approve pulmonary services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for chemotherapy administration service provided on May 20, 2020.
You asked the Plan to waive the deductible for professional service. You say that you should not be billed this amount because you purchased this drug yourself at the pharmacy. The Plan denied your request. The Plan says the deductible amount you are being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $1,250 deductible for a professional chemotherapy administration service. At the time this claim was processed, $65.97 of the $1,250 deductible had been met. The allowed amount of this service is $75.59, resulting in a deductible obligation of $75.59. The item or service you asked the Plan to waive the deductible for falls within the benefit category Physician/Practitioner Services, Including Doctor's Office Visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $1,250 deductible for Physician/Practitioner Services, Including Doctor's Office Visits. This cost sharing is a contractual obligation that had not been met at the time professional service was received on May 20, 2020. Therefore, we decided that the Plan does not have to waive the deductible for chemotherapy administration service provided on May 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Insulin provided on February 1, 2020 and February 2, 2020.
You asked the Plan to pay for the Insulin. You say that this was not a self-administered drug. You also say that you do not need or use insulin on a daily basis, and this was administered during a brief hospital stay. The Plan denied your request. The Plan says this is a self-administered drug and is not Part B covered.
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 Insulin provided on February 1, 2020 and February 2, 2020.
Benefits for the Insulin 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on June 
3, 2019. 
 
You asked the Plan to pay for the drug testing. You say that this was medically necessary testing. The Plan 
denied your request. The Plan says there is no evidence that this testing was ordered. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by the 
treating provider.  
 
We looked at the file and Medicare rules. The file does not include an order signed by the provider indicating 
this testing was requested. Based on this information, we decided that Medicare rules for coverage of the drug 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the presumptive and 
definitive drug testing provided on June 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid services you received on February 3, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not covered when provided by an out-of-network provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aid services only when they are provided by an in-network provider. We looked at the file and the Plan's rules. The hearing aid services in question were provided by an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid services you received on February 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, first intraoral periapical x-ray, each additional intraoral periapical x-ray, bitewings, and prophylaxis provided on January 21, 2020 by an OON provider.
You asked the Plan to pay for the dental services. You say that you cannot afford to pay for these services, which is why you have insurance. The Plan denied your request. The Plan says the treating provider is OON. The Plan also says that services done by an OON dentist are 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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, first intraoral periapical x-ray, each additional intraoral periapical x-ray, bitewings, and prophylaxis provided on January 21, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a tuberculosis test (86580) provided on February 3, 2020.
You asked the Plan to pay for a tuberculosis test. You say that this is a separately payable screening test. The Plan denied your request. The Plan says this is not a covered test when performed for screening purposes.
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, a tuberculosis 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 a tuberculosis test (86580) provided on February 3, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications. The enrollee had stable vital signs. The enrollee was treated for pain with effect. The enrollee required maximum assistance of two with functional mobility. The enrollee required varying assistance with activities of daily living. The enrollee was non-weight bearing to the left lower extremity. The documentation does not support that the enrollee requires the specialized skills, knowledge, or judgment of a skilled professional nurse or qualified therapist to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis, at a SNF 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered from February 21, 2020 to February 24, 2020.
You asked the Plan to waive the copayment for these services. You say that the charges are too high. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for each Medicare-covered outpatient surgical service.
Review of the file shows that you received outpatient surgical services from February 21, 2020 to February 24, 2020. You have been asked to pay a $200 copayment for these services. These services fall within the Medicare-covered outpatient surgical service benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The file shows that the statement from March 21, 2020 did not show a $200 responsibility because the claim was still pending with the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered from February 21, 2020 to February 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive your payment for the complete maxillary denture provided on April 30, 2019.
You asked the Plan to waive your payment for the complete maxillary denture. You say that you do not agree with the price that the dentist charged you for your upper denture. You also say that you feel the denture was not made correctly. The Plan denied your request. The Plan says the Plan paid their portion of the cost share for your denture.
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 contract clearly states that you are responsible for a 50% coinsurance for the listed services when they are received by an in-network provider. The Plan is only obligated to pay 50% of the cost share. Therefore, we decided that the Plan does not have to waive your payment for the complete maxillary denture provided on April 30, 2019.