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

We decided that the Plan does not have to pre-approve a regimen of Carboplatin (J9045), Pemetrexed (J9305),
Pembrolizumab (J9271), Bevacizumab (Q5107), and Pegilgrastim (Q5108).
You asked the Plan to pre-approve a regimen of Carboplatin, Pemetrexed, Pembrolizumab, Bevacizumab, and
Pegilgrastim. You say that this is medically necessary. The Plan denied your request. The Plan says this
regimen is not supported.
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 a regimen of Carboplatin, Pemetrexed,
Pembrolizumab, Bevacizumab, and Pegilgrastim. Our reviewer says that a regimen of Carboplatin,
Pemetrexed, Pembrolizumab, Bevacizumab, and Pegilgrastim is not supported in this case. Our physician
reviewer found this combination of drugs is not FDA-approved for the enrollee's diagnosis or 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 a regimen of Carboplatin, Pemetrexed, Pembrolizumab, Bevacizumab, and
Pegilgrastim have not been met. Therefore, we decided that the Plan does not have to pre-approve a regimen of
Carboplatin (J9045), Pemetrexed (J9305), Pembrolizumab (J9271), Bevacizumab (Q5107), and Pegilgrastim
(Q5108)
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plandoes not haveto pay fornon-emergent transportation provided to the enrollee on May 26, 2020.You asked the Planto pay forthe transportation. You say that this should be paid for.The Plandenied your request. The Plansaysthis is not covered by the plan or Medicare.The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of the transportation have not been met.Therefore, we decided that the Plandoes not haveto pay fornon-emergent transportation provided to the enrollee on May 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for intravenous infusion therapy provided
from May 12, 2020, to May 20, 2020.
You asked the Plan to waive the copayments for intravenous infusion therapy. You say that you disagree with
the charges and feel that they are too high and should not qualify as surgical procedures. 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 $285
copayment for outpatient hospital services.
You received intravenous infusion therapy from May 12, 2020, to May 20, 2020, for a total of five visits.
Therefore, you are responsible to pay the allowed amount of $174.52, which is less than the $285 copayment,
per each visit. The total amount you owe is: $872.60.
You have been asked to pay the total copayment amount of $872.60 for intravenous infusion therapy.
Intravenous infusion therapy falls 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 copayments for intravenous infusion therapy provided from May 12, 2020, to May
20, 2020
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for infectious agent detection (87631) provided on June 16, 2020.
You asked the Plan to pay for the infectious agent detection. You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says that this is not a Medicare covered
benefit.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The
rules also say that CPT code 87631 is a Group 1 code.
We find that CPT code 87631 is supported in the record. Specifically, per the Local Coverage Article for the
laboratories state, CPT code 87631 is valid for Medicare purposes. Based on this information, we decided that
Medicare rules for coverage of the infectious agent detection have been met. Therefore, we decided that the
Plan has to pay for infectious agent detection (87631) provided on June 16, 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive thecoinsurance foroutpatient therapy services provided from March 2, 2020, through March 6, 2020.You asked the Plan to waive the coinsurance foroutpatient therapy services. You say that the bill should be corrected and covered in full.The Plandenied your request. The Plan says the coinsurance 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 20% coinsurance for each Medicare-covered physical therapy, speech language therapy and occupational therapy visit.You have been asked to pay $13, which is 20% of the allowed amount for each outpatient therapy service. The allowed amount is $65 (20% x $65 = $13). The total amount you owe is $156 ($13/ service x 12 services = $156). Outpatient therapy falls within the "Outpatient Rehabilitation 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 coinsurance foroutpatient therapy servicesprovided from March 2, 2020, through March 6, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided by an OON provider.

You asked the Plan to pay fora transthoracic echocardiography. You say that it is the legal responsibility of the insurer to pay medical claims for medically necessary procedures.The Plan denied your request. The Plan says rules for payment have not been met.

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 OON provider
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay foran abutment and crown on tooth #29 (D6057, D6065) provided July 8, 2020.You asked the Plan to pay forthe abutment and crown. You say that these services were medically necessary.The Plan denied your request. The Plan says that these items are only covered when there was an implant placed. The plan argues no implant was placed.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 abutment and 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 Planwas correct in denying the request to pay for the abutment and crown. Our reviewer says that the service was medically necessary. Our physician reviewer found the patient's dental record indicates that an implant body was placed on February 20, 2020. Therefore, placement of the implant abutment and implant supported crown is reasonable and necessary.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 abutment and crown have been met.Therefore, we decided that the Plan has to pay foran abutment and crown on tooth #29 (D6057, D6065) provided July 8, 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 toopen the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe etonogestrel implant system.You asked the Plan to pay forthe etonogestrel implant system. You say that this has always been covered by insurance. You say that you were never informed this wouldn't be covered.The Plan denied your request. The Plan says your plan does not provide coverage for this service.The Plan must follow Medicare rules. The rules say that items/services for the purposes of preventing conception (contraception) are not considered medically reasonable and necessary. Records show that the requested service is primarily for the purpose of contraception. The documentation does not show that this service is being requested to treat a specific illness/injury. As such, the Medicare rules for coverage of this item/service have not been met.Therefore, we decided that the Plan does not have to pay forthe etonogestrel implant system.Benefits for the etonogestrel implant systemmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for percutaneous transcatheter placement of
drug eluting intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or
branch (C9600-LD) provided on July 20, 2020.
You asked the Plan to waive the coinsurance for an outpatient surgery. You say that you were seen for an
emergency room visit and should not be billed for other items during an emergency. The Plan denied your
request. The Plan says the correct coinsurance 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 30%
coinsurance for outpatient hospital services.
You have been asked to pay 30% coinsurance for an outpatient surgery. An outpatient surgery falls 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 coinsurance for
percutaneous transcatheter placement of drug eluting intracoronary stent(s), with coronary angioplasty when
performed; single major coronary artery or branch (C9600-LD) provided on July 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the MRI, brain (including brain stem); without contrast material) (CPT Code 70551-26) provided on July 8, 2020.
You asked the Plan to pay for the services. You say that this denied as duplicate in error. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Records reviewed do not support the service being performed by the rendering provider were provided more than once for this date of service.
Therefore, the recommendation for CPT code 70551-26 is to uphold original denial. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the MRI, brain (including brain stem); without contrast material) (CPT Code 70551-26) provided on July 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the intermittent urinary catheters provided on April 16, 2020.
You asked the Plan to pay for the intermittent urinary catheters. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the documentation did not include an
itemized shipping/billing invoice.
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 for the supplies provided in this case. Review of the file
shows that the documentation did not include an itemized shipping/billing invoice to indicate the specific
supplies or proof of delivery. 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 intermittent
urinary catheters provided on April 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe extraction provided on July 2, 2020 by an OON provider.You asked the Plan to pay forthe extraction. You say that you feel that this service should be covered by your insurance.The Plan denied your request. The Plan says this service was rendered by a non-participating provider. The Plan also says that a prior authorization was not obtained.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 forthe extraction provided on July 2, 2020 by an OON provider.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that the services are medically necessary.The Plan denied your request. The Plan says that the enrollee has no complex rehabilitation needs.The Plan must follow Medicarerules. 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 care. Our reviewer says that the requested SNF services are medically necessary. Our physician reviewer found the enrollee is functioning below her baseline and has not yet been shown to have reached a new plateau in function. Daily skilled services are required to establish a maintenance program and to prevent deterioration of the enrollee's condition.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 care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted.Therefore, we decided that the Plan has to pre-approveskilled nursing facility (SNF) care.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: Surgery
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 specialist services. You say that there was a misconception and this enrollee was called in for treatment without a valid referral.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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided.

You asked the Plan to pay for the dental services. You say that you are requesting reimbursement.The Plan denied your request. The Plan says services performed by a provider that has opted out of Medicare are not covered.

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 a provider who has opted out of the Medicare program.Therefore, we decided that the Plan does not have to pay for dental services provided.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrolle.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 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 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.
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-ofnetwork
provider on January 15, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are
available in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan 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 January 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulation, application of a modality services, and the office visit received. 

You asked the Plan to pay for the electrical stimulation, application of a modality services, and the office visit. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services received are not covered.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay for the electrical stimulation, application of a modality services, and the office visit received.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for inpatient hospital care and primary care 
visits provided from January 2, 2020, to September 17, 2020. 
 
You asked the Plan to waive the cost-sharing for inpatient stay and primary care visits. You say that you cannot 
afford these expenses. The Plan denied your request. The Plan says the copayment amounts you are being 
charged are correct. 
 
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 $570 
copayment per day for days 1 to 3 of inpatient care and $35 copayment for each primary care visit. The 
inpatient stay lasted 9 days, resulting in a copayment amount of $1,710. There were 17 primary care visits, 
resulting in a total copayment of $595. Your total copayment obligation is therefore $2,305. 
 
You have been asked to pay $570 copayment per day for days 1 to 3 of inpatient care and $35 copayment for 
each primary care visit. Inpatient stay and primary care visits fall within the "Inpatient Hospital Care" and 
"Physician/Practitioner Services, Including Doctor's Office Visits" benefit categories. 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 cost-sharing for inpatient hospital care and primary care visits provided from January 2, 2020, to 
September 17, 2020.