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

We decided that the Plan has to pre-approve a 90 day supply of Cellcept 250 MG.
You asked the Plan to pre-approve the 90 day supply. You say that you would like reconsideration because going to a pharmacy 12 times a year puts you at more risk. The Plan denied your request. The Plan says that this benefit is generally limited to a 30-day supply.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the 90 day supply. Our reviewer says that the requested items/services are considered medically reasonable and necessary given the extended length of time patient has been on medication to get 90 day prescription. Our physician reviewer found it is not likely dosage will be adjusted, not typically titrated this far out from transplant. 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 90 day supply have been met. Therefore, we decided that the Plan has to pre-approve a 90 day supply of Cellcept 250 MG.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a replacement hearing aid provided on August 7, 2020.
You asked the Plan to pay for the hearing aids. You say that you took out insurance to cover the potential loss of a hearing aid and only want reimbursement for the cost of the replacement. The Plan denied your request. The Plan says neither Medicare nor your Plan cover hearing aids.
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related services. Though the hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these types of items and services. Therefore, we decided that the Plan does not have to pay for the replacement hearing aid provided on August 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the trabeculoplasty laser surgery provided on October 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the trabeculoplasty laser surgery. You say that the services were medically necessary. 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 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 trabeculoplasty laser surgery provided on October 23, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that you would like reconsideration because the member's bone density is decreasing and they cannot tolerate bisphosphonates. The Plan denied your request. The Plan says the bone density testing shows the member has osteopenia and not osteoporosis.
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 Prolia. Our reviewer says that the review indicates that the enrollee has osteopenia. The requested use of Prolia is no FDA-approved for the enrollee's diagnosis. Our physician reviewer found its use is not supported by one of the major drug compendia or by clinical research that appears in a 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 10, 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 testing is not covered.
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 cardiovascular risk assessment panel, 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 the laboratory services rendered on November 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lenses (V2781) provided by an out-of-network
provider on November 18, 2020.
You asked the Plan to pay for the progressive lenses. You say that the Plan should make an exception because
you needed to see an out-of-network provider to stay within the $300 cost limit. The Plan denied your request.
The Plan says they do not cover routine vision services or eyewear that is provided out of network.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services for up to $300 when they are provided in-network.
We looked at the file and the Plan's rules. The Plan only covers routine vision care and eyewear when it is
provided in-network. You received your eyewear out-of-network. Based on this information, we decided that
the Plan's rules for coverage of the progressive lenses have not been met. Therefore, we decided that the Plan
does not have to pay for progressive lenses (V2781) provided by an out-of-network provider on November 18,
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetic test strips (A4253) purchased from an internet
retailer on January 22, 2020.
You asked the Plan to pay for diabetic test strips. You say that the internet retailer is cheaper for you than
obtaining the requested items through the pharmacy. The Plan denied your request. The Plan says rules for
payment have not been met because the internet retailer is an out of network provider.
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare
program.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of diabetic test strips have not been met. Specifically, the items at issue were provided by a provider
that appears to not be certified for Medicare. The provider at issue did not come up on the Medicare.gov search
for durable medical equipment (DME) suppliers serving your area. There was no documentation supplied by
the provider to verify that they are certified by Medicare. Therefore, we decided that the Plan does not have to
pay for diabetic test strips (A4253) purchased from an internet retailer on January 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory panel testing provided on August 11, 2020.
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing was ordered for screening purposes and is not covered.
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 tests at issue in this appeal, lab tests, were requested for screening purposes. Medicare does not cover these tests for screening purposes. Therefore, we decided that the Plan does not have to pay for laboratory panel testing provided on August 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided on November 15, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the home visit. You say that the services were medically necessary. 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 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 home visit provided on November 15, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor and supplies (K0553, K0554) provided November 19, 2020.
You asked the Plan to pay for the therapeutic continuous glucose monitor and supplies. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the delivery ticket submitted did not include the carrier's tracking number.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery. In this case, the record is missing a proof of delivery that illustrates that the items were delivered to the enrollee. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the therapeutic continuous glucose monitor and supplies (K0553, K0554) provided November 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator and supplies provided by an out-of-network provider from October 9, 2020, through December 9, 2020.
You asked the Plan to pay for the neuromuscular stimulator and supplies. You say that your physical therapist was supposed to send in the prior authorization. You say that you were told this was covered. The Plan denied your request. The Plan says prior authorization was required but 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 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 neuromuscular stimulator and supplies provided by an out-of-network provider from October 9, 2020, through December 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the refraction (92015) provided on December 1, 2020.
You asked the Plan to pay for the refraction. You say that you would like reconsideration because the services were provided for a critical medical issue. The Plan denied your request. The Plan says eye refraction is only covered when performed as routine.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when rendered as part of a routine eye exam. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the refraction have not been met. Specifically, the eye exam was not routine and was rendered for a medical condition. Per the EOC, refractions are only covered when provided as part of a routine exam. Therefore, we decided that the Plan does not have to pay for the refraction (92015) provided on December 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for continuous glucose monitor system and supplies provided on November 4, 2020 and supply allowance provided on December 4, 2020.
You asked the Plan to pay for the continuous glucose monitor (CGM) system and supplies. You say that the Plan should pay these claims. The Plan denied your request. The Plan says medical records supporting medical necessity were requested but not received.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The submitted physician order does not support criteria or medical necessity for the items. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for continuous glucose monitor system and supplies provided on November 4, 2020 and supply allowance provided on December 4, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the office visit provided by an out-of-network provider on June 30, 2020.
You asked the Plan to pay for the office visit. You say that you were not in New York and had no choice but to go out-of-network. You say that you should not be responsible for the bill. The Plan denied your request. The Plan says that you must use a network provider.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not submit medical records. This means we cannot determine if the Plan's denial of non-emergent services is justified. Therefore, we decided that the Plan has to pay for the office visit provided by an out-of-network provider on June 30, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on September 22, 2020.
You asked the Plan to pay for the limited oral evaluation. You say that this was an emergency situation. You say that you were in extreme pain. You also say that you have never had a problem with getting emergency services in the past. The Plan denied your request. The Plan says limited oral evaluation is not listed and therefore is not 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 limited oral evaluation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on September 22, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the coinsurance for the technetium-99 provided on December 1, 2020.
You asked the Plan to waive the coinsurance for the technetium-99. You say that you received a bill for durable medical, but no equipment was supplied at the time of the nuclear test. You say that charge should be in the total amount of the SPECT study. The Plan denied your request. The Plan says that the coinsurance applied correctly.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not submit the 2020 Evidence of Coverage. This means that we cannot determine if the coinsurance you are being asked to pay is correct or justified by the Plan contract. Therefore, we decided that the Plan has to waive the coinsurance for the technetium-99 provided on December 1, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the two procedures to remove a torus mandibularis (D7473) provided on September 16, 2020.
You asked the Plan to pay for the dental surgeries. You say that both you and the provider had obtained prior authorization before these services and you do not understand why they are being denied now. The Plan denied your request. The Plan says that removal of the torus mandibularis is not covered by Medicare or by the Plan's supplemental dental benefit. The Plan also states that they have no record of a prior authorization for these services, and there is no documentation of a call asking for this specific 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. The Plan states that there is no coverage for removal of a torus mandibularis, and we are unable to verify any possible prior authorizations or phone calls as this documentation was not included in the case file.
However, we found that code D7473 is classified as oral and maxillofacial surgery. The Plan contract states that oral surgery can be covered for up to two procedures per calendar year. We requested additional information from the Plan to see if they had a comprehensive list including specific codes that are covered or excluded under oral surgery. The Plan stated that the services listed in the contract are all that is available to make the determination. Removal of a torus mandibularis is considered oral surgery, and the Plan states they can cover up to two oral surgery procedures per year. Therefore, it is reasonable to expect the Plan to pay for the two procedures to remove a torus mandibularis (D7473) provided on September 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit provided June 15, 2020.
You asked the Plan to pay for the office visit. You say that considering life being turned upside with COVID, you were planning and then had surgery from which you are still recovering. Please reconsider. The Plan denied your request. The Plan says If you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the outpatient office visit provided June 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete denture - mandibular (D5120) and complete denture - maxillary (D5110) provided November 10, 2020.
You asked the Plan to pay for the complete dentures. You say that you did not know the dentist was not covered. The Plan denied your request. The Plan says the dental provider has opted out of Original Medicare and therefore the services 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. The Plan covers the complete dentures when you see a licensed dental provider who has not opted out of Original Medicare. We looked at the file and Medicare rules. The request is for services which were provided by a dentist who has opted out Medicare. Based on this information, we decided that the Plan's rules for coverage of the complete dentures have not been met. Therefore, we decided that the Plan does not have to pay for the complete denture - mandibular (D5120) and complete denture - maxillary (D5110) provided November 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 15, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that the services were medically necessary. 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 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 provided on January 15, 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 (81173, 81201, 81120, 81121) provided on November 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 out-of-network services were not pre-authorized.
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 services at issue in this appeal. The Plan did not pre-approve the service 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 lab services (81173, 81201, 81120, 81121) provided on November 6, 2020.
Sincerely