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

We decided that the Plan does not have to pre-approve Repatha, 140 mg/ml, Sureclick.
You asked the Plan to pre-approve Repatha Sureclick. You say that the enrollee has coronary artery disease. The Plan denied your request. The Plan says Repatha Sureclick is considered a self-administered drug. The Plan says self-administered drugs are only covered under a Prescription Drug Plan. The Plan also says you have a medical only policy 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 Repatha, 140 mg/ml, Sureclick.
Benefits for Repatha Sureclick 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Kate Farms Peptide and Pro-source enteral feeding
formula (B4155, B4153).
You asked the Plan to pre-approve the specialty enteral feeding formula. You say that the specialty formula is
medically necessary. The Plan denied your request. The Plan says the plan covers other brands of lactose-free
feeding formula such as Isosource.
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 the specialty enteral feeding formula.
Our reviewer says that the requested items are not considered medically necessary in this case. Our physician
reviewer found the enrollee is lactose intolerant. The plan noted other covered enteral feed formulations that do
not have lactose. The provider did not address why these formulations would not be tolerated.
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 specialty enteral feeding formula have not been met. Therefore, we decided
that the Plan does not have to pre-approve Kate Farms Peptide and Pro-source enteral feeding formula (B4155,
B4153).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient office visit provided on November 4, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an outpatient office visit. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was 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 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 an outpatient office visit provided on November 4, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pontic-porcelain fused to noble metal for tooth 12 (D6242) and retainer crown- porcelain fused to noble metal for tooth 10 & 11 (D6752).
You asked the Plan to pre-approve the dental services. You say that the service is medically necessary. The Plan denied your request. The Plan says the chart notes document extensive decay and you were advised of a questionable prognosis for the bridge. The Plan states their dental consultant determined that although a poor quality of the bridge is not found, the diagnosis is questionable and the bridge did fail. The Plan states they consider the bridge 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. The Plan covers the dental services when the services are medically necessary and reasonable. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. This is not covered due to a poor prognosis. Therefore, we decided that the Plan does not have to pre-approve pontic-porcelain fused to noble metal for tooth 12 (D6242) and retainer crown- porcelain fused to noble metal for tooth 10 & 11 (D6752).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the emergency services provided September 16, 2019.
You asked the Plan to waive the coinsurance for the emergency services. You submitted the bill for review. 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 20% coinsurance for up to a maximum of $120 for each Medicare-covered service. You have been asked to pay $25.25 which is 20% of the allowed amount for the emergency services. The allowed amount is $126.23. ($126.23 x 20% = $25.25). The emergency services fall within the "Emergency 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 coinsurance for the emergency services provided on September 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 26, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
You asked the Plan to pre-approve the Keytruda. You say that the information provided supports the need for Keytruda. The Plan denied your request. The Plan says the enrollee does not meet the clinical criteria for coverage. The Plan says that the records do not show that the enrollee's tumors express PD-L1 receptors.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Keytruda. Our reviewer says that Keytruda is not medically reasonable and necessary. Our physician reviewer found Keytruda is not FDA approved for monotherapy in patients with PD-L1 expression of 0%. Off-label use is not supported by major drug compendia or in medical literature. 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 Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the
sacroiliac joint, with image guidance (64625).
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's
denial. The Plan denied your request. The Plan says that this service is considered experimental and
investigational; therefore, it is not a covered procedure.
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 this service. Our reviewer says that this
service is not medically necessary. Our physician reviewer found that radiofrequency ablation is considered an
experimental/ investigational procedure because of the wide variation of effectiveness indicated in the reviewed
literature. Therefore, your request is considered not medically necessary or reasonable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not
have to pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance
(64625).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assistant surgeon services rendered on October 15, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT codes 58720 and 58542. The Medicare Fee Schedule Database contains a surgical indicator of 1 for these procedures. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for these services have not been met.Therefore, we decided that the Plan does not have to pay forthe assistant surgeon services rendered on October 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.
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 rendered by an out-of-network provider without prior authorization.
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 medical services 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 copayment for the specialist services rendered on February 13, 2019 and August 14, 2019.
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. 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 $45 copayment for each specialist visit for Medicare-covered benefits.
Review of the file shows that you received ophthalmology services on February 13, 2019 and August 14, 2019. You have been asked to pay a $45 copayment per date of service for these services, for a total of $90. These services fall within the specialist visit for Medicare-covered benefits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the specialist services rendered on February 13, 2019 and August 14, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan and an ultrasound provided on
October 29, 2019 to November 8, 2019.
You asked the Plan to waive the copayment for a CT scan and an ultrasound. You say that you had a CT scan
of your liver and only paid a $75 copayment and disagree with the $150 charge. The Plan denied your request.
The Plan says the claims were processed correctly and you are being charged the correct 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 $75
copayment for each radiological diagnostic service.
You had a CT scan on October 29, 2019. Therefore, you are responsible to pay the $75 copayment.
You had an ultrasound on October 29, 2019. Therefore, you are responsible to pay the $75 copayment.
You had a CT scan on November 8, 2019. Therefore, you are responsible to pay the $75 copayment.
The total amount you owe is: $225.
You have been asked to pay the total copayment amount of $225 for a CT scan and an ultrasound. A CT scan
and an ultrasound fall within the outpatient diagnostic tests and therapeutic services and supplies benefit
category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to waive the copayment for a CT scan and an ultrasound provided on
October 29, 2019 to November 8, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (Denosumab).
You asked the Plan to pre-approve the Prolia. The Plan denied your request. The Plan says the documentation
does not meet the Plan's medical necessity guidelines for coverage.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 Prolia. Our reviewer says that the
Prolia (Denosumab) is not medically necessary. Our physician reviewer found the enrollee has no tried and
failed the required drug, Zoledronic Acid. Our reviewer also found that the documentation does not support
that Zoledronic Acid would likely be less effective, and/or would likely have adverse effects for the enrollee in
this case.
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 Prolia have not been met. Therefore, we decided that the Plan does not have
to pre-approve Prolia (Denosumab).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve white glass with high gold content crown, tooth #9 (D2750), for the enrollee.
You asked the Plan to pre-approve the dental services. You say that the service is medically necessary. The Plan denied your request. The Plan says placing a crown on tooth #9 is not reasonable or necessary and does not meet the coverage criteria under the member's supplemental benefits. The Plan states there are other treatments for this tooth which may be medically appropriate or necessary. The Plan states this does not mean the member cannot receive a crown on tooth #9, it simply means the member's supplemental dental benefits do not cover a crown for this situation.
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 rules have not been met. There is not pathologic destruction to the tooth involving four or more surfaces and at least 50% of the incisal edge. Therefore, we decided that the Plan does not have to pre-approve white glass with high gold content crown, tooth #9 (D2750), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the provisional crown (D2799) provided on January 2, 2020.
You asked the Plan to pay for the dental service. You say that you chose to have the crown done to restore your tooth for as long as possible. You also say that had you known that this was not covered, you would have had the tooth pulled instead. The Plan denied your request. The Plan says the provisional crown is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the provisional crown is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the provisional crown (D2799) provided on January 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for 1 additional extraction provided on December 7, 2019.
You asked the Plan to pay for 1 additional extraction. You say that the provider's office staff advised you could have up to 4 teeth extracted and it would not cost more than $250. You also say that you were misguided by the office staff. The Plan denied your request. The Plan says 2 extractions per calendar year are covered with a 50% coinsurance. The Plan also says the frequency limit has been exceeded.
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 extractions are a covered service, there is a benefit limit of 2 extractions per calendar year. The record shows that the Plan paid for 2 extractions that you received on December 7, 2019. Therefore, we decided that the Plan does not have to pay for 1 additional extraction provided on December 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the office visit and laboratory services
rendered.
You asked the Plan to waive the copayments for these services. You say that you didn't schedule an office visit
and only walked in for labs. 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 each covered visit or consultation in an outpatient location with your PCP or other primary care
physician and a $10 copayment per day for Medicare-covered laboratory tests.
Review of the file shows that you received PCP office visit services on October 23, 2019. You have been asked
to pay a $10 copayment for these services. These services fall within the covered visit or consultation in an
outpatient location with your PCP or other primary care physician 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 you also received lab services. You have been asked to pay a $10
copayment for these services. These services fall within the Medicare-covered laboratory tests 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 copayments for the office visit and laboratory
services rendered.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve premoistened washcloths.
You asked the Plan to pre-approve premoistened washcloths. You say that you need these due to the enrollee's incontinence. The Plan denied your request. The Plan says this is excluded from coverage by Medicare.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve premoistened washcloths.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an allowance for health food purchases and/or electricity, water and/or phone bill payments.
You asked the Plan to pre-approve the card allowance. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says you do not meet the Plan coverage criteria for this service.
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the card allowance have not been met. Specifically, the record indicates that you do not require intensive care coordination, therefore you do not meet coverage criteria. Therefore, we decided that the Plan does not have to pre-approve an allowance for health food purchases and/or electricity, water and/or phone bill payments.