Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair and oximeter.
You asked the Plan to pre-approve a shower chair with commode and oximeter. You say that these items are medically necessary. The Plan denied your request. The Plan says these items are not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that shower equipment and oximeters are not covered because they are not primarily medical in nature. While these items 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 a shower chair with commode and oximeter.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Keytruda/Carboplatin/Paclitaxel/Palonosetron/Dexamethasone/Fosaprepitant for the enrollee.
You asked the Plan to pre-approve the drug regimen. You say that this is medically necessary. The Plan denied your request. The Plan says that the use of these drugs requires previously untreated stage II or III triple-negative breast cancer.
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 drug regimen. Our reviewer says that the requested drug regimen is medically reasonable and necessary. Our physician reviewer found the enrollee's oncologist writes that the enrollee's carcinoma is more of a triple-negative pattern, given the very weak, low level staining of estrogen receptor and less than 1%, progesterone receptor and negativity by FISH studies for HER-2/neu. The enrollee is an 80-year-old woman with newly diagnosed, poorly differentiated clinical T4, N2, stage IIIB inflammatory breast carcinoma. PR and HER2 negative, very low ER positivity. It has been shown that a majority of low ER positive breast cancers behave like hormone receptor negative tumors. 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 drug regimen have been met. Therefore, we decided that the Plan has to pre-approve Keytruda/Carboplatin/Paclitaxel/Palonosetron/Dexamethasone/Fosaprepitant for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the Part B injections provided from December 26, 2019 to February 20, 2020.
You asked the Plan to reduce the coinsurance for the Part B injections. You say that you were told the infusions would cost 20% of $40.00 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 in-network Part B injectable drugs that are not self-administered. You have been asked to pay $480 which is 20% of the allowed amount for each of the Part B injections. The allowed amount is $2,400. ($2,400 x 20% = $480). The Part B injections falls within the "Medicare Part B prescription drugs" 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 reduce the coinsurance for the Part B injections provided from December 26, 2019 to February 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic casts (D0470) provided on January 20, 2020.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the
denied charges. The Plan denied your request. The Plan says the service is not a covered benefit under the plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. The service is not listed in your EOC as a covered benefit; therefore,
the services are not covered. Therefore, we decided that the Plan does not have to pay for diagnostic casts
(D0470) provided on January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided out of network on December 16, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The 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 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 physician services provided out of network on December 16, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for a resin-based composite (CPT D2391) and the re-cement or re-bond of a fixed partial denture (CPT D6930) provided on December 11, 2019.
You asked the Plan to pay for the resin-based composite and the re-cement or re-bond of a fixed partial denture. You say that you upgraded your dental plan and the benefits state that the repair of a tooth is covered. You say that the services in dispute should not have been denied. The Plan denied your request. The Plan says that the tooth surface is missing or invalid. The Plan says that the procedure is not a benefit under the dental plan.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for the resin-based composite and the re-cement or re-bond of a fixed partial denture by a contract provider. The file does not show that the Plan provided notice that the resin-based composite and the re-cement or re-bond of a fixed partial denture would not be covered. Under Medicare rules, this means the resin-based composite and the re-cement or re-bond of a fixed partial denture is considered approved by the Plan. It was reasonable, based on the contract language and your having gone to see an in-network dentist, for you to have believed the services in dispute were covered. Therefore, we decided that the Plan has to pay for a resin-based composite (CPT D2391) and the re-cement or re-bond of a fixed partial denture (CPT D6930) provided on December 11, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient therapy services provided on July 15, 2019 by an out of network (OON) provider.
You asked the Plan to pay for these services. . You say that this service should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The contract with the Plan also states outpatient therapy requires prior authorization both in network and out of network. The 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 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 the outpatient therapy services provided on July 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 wrist hand orthosis (L3916) provided to the enrollee on
January 6, 2020.
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary.
The Plan denied your request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the orthosis have not been met. Documentation submitted did not
indicate the provider discussed the need for the billed supply code; therefore the billed supply code cannot be
verified. Therefore, we decided that the Plan does not have to pay for wrist hand orthosis (L3916) provided to
the enrollee on January 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided to the enrollee on
December 27, 2019.
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary.
The Plan denied your request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the orthosis have not been met. Documentation submitted did not
indicate the provider discussed the need for the billed supply code; therefore the billed supply code cannot be
verified. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided
to the enrollee on December 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve hearing aids. You say that you have had a negative experience with the Plan provider. The Plan denied your request. The Plan says that out-of-network care is 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve hearing aids to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the off-label use of this drug is not medically accepted per Medicare rules, and is not covered based on the available information.
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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the review relates to a request to use Rituxan in combination with Gemcitabine to treat a 69 year old woman with relapsed peripheral t-cell lymphoma with aberrant CD20 co expression. The requested use is not FDA approved. The requested use is not supported in any of the CMS approved compendia. There are no supporting citations in a PubMed search. The NCCN Guidelines Version 1.2020 Peripheral T-Cell Lymphomas do not include Rituxan among the treatment regimens. The use is not listed as not indicated, not supported or not recommended in any of the compendia. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituxan for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT codes J2357 and 96401 provided on July 20, 2018.
You asked the Plan to pay for CPT codes J2357 and 96401 provided on July 20, 2018. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the records provided do not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. We looked at the file and Medicare rules. The medical records do not document how many units were administered and how many units were discarded to verify the correct units were billed. Therefore, we decided that the Plan does not have to pay for CPT codes J2357 and 96401 provided on July 20, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1833), lumbar-sacral orthosis (L0650) and
suspension sleeve (L2397) provided to the enrollee on November 11, 2019.
You asked the Plan to pay for the orthoses and sleeve. You say that the durable medical equipment is medically
necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of an
established relationship between the member and the ordering physician. The Plan states there were no claims
submitted for an evaluation and management service. The Plan states the review of claims history for this
member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or
Telehealth service with the ordering physician as required per CMS guidelines.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1833),
lumbar-sacral orthosis (L0650) and suspension sleeve (L2397) provided to the enrollee on November 11, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve physical therapy services to be provided by an OON provider. You say that you need to go to the OON provider because the in network facility is too far of a drive for you right now. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria has 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve physical therapy services to be 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 the dental cleaning provided on July 8, 2019.
You asked the Plan to pay for the cleaning. You say that you have never had to verify if the supervising dentist
participated with his plan. The Plan denied your request. The Plan says that this procedure is not a covered
benefit when performed by a dentist who has affirmatively opted of Medicare participation.
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 says that if you
receive services from a Dentist that has affirmatively opted not to participate with Medicare you will be
responsible for all costs.
We looked at the file and Medicare rules. The file indicates you received these services from a dentist who has
opted not to participate in Medicare. Based on this information, we decided that the Plan's rules for coverage of
the cleaning have not been met. Therefore, we decided that the Plan does not have to pay for the dental
cleaning provided on July 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the observation stay provided from October
4, 2019 through October 10, 2019.
You asked the Plan to waive the copayment for the observation stay. You say that you were in the emergency
room. You say that you should have a $50 copayment. The Plan denied your request. The Plan says the
copayment 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 $75
copayment for all other outpatient hospital services. Covered services include services in an emergency
department or outpatient clinic, such as observation services or outpatient surgery.
You have been asked to pay a $75 copayment for the observation stay. The observation stay falls within the
"Outpatient hospital services" benefit category. The records show that you were admitted to outpatient
observation. 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 observation stay provided from October
4, 2019 through October 10, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve admission to an inpatient mental health facility for the enrollee.
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that this is medically necessary. The Plan denied your request. The Plan says that this may be appropriate for a different level of care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric hospital services. Our reviewer says that the requested services are medically reasonable and necessary. Our physician reviewer found based on a review of the records provided, the enrollee does meet the criteria for this admission, as the enrollee was shown to have hallucinations and paranoid delusions. It did appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower 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 inpatient psychiatric hospital services have been met. Therefore, we decided that the Plan has to pre-approve admission to an inpatient mental health facility for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee out of network on January 24, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The 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 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 physician services provided to the enrollee out of network on January 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a 3X Q-logic joystick expandable controller.
You asked the Plan to pre-approve a 3X Q-logic joystick expandable controller. You say that the enrollee needs a 3X Q-logic joystick expandable controller. The Plan denied your request. The Plan says this upgraded joystick is not medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a 3X Q-logic joystick expandable controller.